COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX00035882 


(Lolumbia  WiniUvmv^     ^ 
in  tlje  €itv  of  i^eto  ^orfe^^H 
^cj^ool  of  Bental  anti  0tal  burger? 


r 


§ 


if 


SURGERY 

OF 

DEFORMITIES  OF  THE  FACE 

INCLUDING  CLEFT  PALATE 


BY 

JOHN  B.  ROBERTS,  A.  M.,  M.  D. 

PROFESSOR   OP  SURGERY   IN   THE     PHILADELPHIA    POLYCLINIC,   SURGEON    TO    THE    METHODIST 
hospital;    FORMERLY   ASSISTANT   EYE   AND   EAR    SURGEON    TO   THE     CHILDREN'S   HOS- 
PITAL, AND  DEMONSTRATOR  OF  ANATOMY  IN  THE  PHILADELPHIA  DENTAL  COLLEGE. 


ILLUSTRATED  WITH  273  FIGURES 


NEW  YORK 
WILLIAM   WOOD   AND   COMPANY 

MDCCCCXII 


2  7 


Copyright,  1912 
By  WILLIAM  WOOD  &  COMPANY 


Printed   by 

The  Maple  Press 

York,  Pa. 


TO 

M.  E.  R. 

MY    COUNSELOR    IN    THE    AFFAIRS    OF    LIFE 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/surgeryofdeformiOOrobe 


PREFACE 


The  appointment  to  deliver  the  Miitter  Lectures  of  the  College  of 
Physicians  of  Philadelphia  for  1900  induced  me  to  give  increased 
attention  to  the  operative  correction  of  facial  deformities.  This  sub- 
ject had  long  interested  me,  and  seemed  an  appropriate  topic  for 
the  lectureship  established  by  Thomas  D.  Mutter,  the  Philadelphia 
teacher,  who  had  played  such  an  important  part  in  the  early  history 
of  plastic  surgery. 

Further  study  has  shown  me  an  ever  widening  field  for  this  depart- 
ment of  surgical  endeavor,  and  given  rise  to  a  consequent  surprise  that 
so  many  sorely  afflicted  persons  fail  to  realize  the  present  possibilities 
of  relief.  Nature  seems  willing  to  aid  the  operator's  efforts  in  an  as- 
tonishing degree,  if  he  use  skill  and  exercise  patience  in  showing  her 
the  way  to  exert  her  reparative  forces. 

J.   B.  R. 
313  South  17th  St.,  Philadelphia. 
March  I,  1912. 


CONTENTS. 


CHAPTER  I. 

Page 

The  Development  of  Plastic  Surgery      1 

CHzlPTER  IL 
A  Survey  of  the  Anatomy  of  the  Face 9 

CHAPTER  in. 
Char.\cteristics  of  Surgery  of  the  Face 29 

CH.APTER  IV. 
The  Principles  of  Plastic  Surgery  of  the  Face 34 

CH.APTER  V. 
Gunpowder  and  Local  Discolorations,  Tattooing        44 

CHAPTER  VI. 
Fistules,  Fissures,  Encephalocele,  Atrophy  and  Hypertrophy  ....      55 

CHAPTER  VII. 

Disfiguring  Skin  Diseases  Requiring  Surgical  Tre.\tment 69 

CHAPTER  VIII. 
Deformities  of  the  Mouth  and  Lips      85 

CHAPTER  IX. 
Harelip  and  Other  Facial  Clefts      99 

CHAPTER  X. 
Cleft  Pa L.\TE 112 

CHAPTER  XI. 

Cheiloplastic    Operations   not    Connected   avith    Harelip   and   Cleft 
Pal.\te 141 

CHAPTER  XII. 

Deformities  of  the  External  Ear 153 

CHAPTER  XIII. 

Deforjiities  of  the  Nose 169 

CHAPTER  XIV. 

Rhinoplasty 195 

CHAPTER  XV. 

Deformities  of  the  Eye-lids  and  Eye-ball 215 

vii 


SURGE  EY  or  DEFORMITIES  OF  THE 
FACE,  INCLUDING  CLEFT  PALATE 


CHAPTER  I. 
THE   DEVELOPMENT   OF  PLASTIC  SURGERY. 

Until  the  revival  of  plastic  operations  upon  the  face  about  a  hundred 
years  ago,  reconstructions  of  lost  areas  of  tissue  and  readjustments 
of  textural  relations  by  operation  had  been  practically  unknown,  to 
the  scientific  world,  for  a  couple  of  centuries.  The  rhinoplastic  and 
cheiloplastic  methods  and  successes  of  Tagiiacozzi  at  Bologna,  detailed 
in  his  work^  published  in  1597,  and  the  methods  used  for  centuries  in 
India  for  restoring  mutilations  of  the  nose  had  been  forgotten  or  were 
disbelieved. 

The  revival,  as  it  may  be  called,  of  plastic  surgery  had  its  beginning 
in  the  middle  of  the  eighteenth  century  when  Rosenstein^  and 
Dubois  and  Boyer^  wrote  discussing  the  possibility  of  restoring  lost 
structures  by  plastic  methods. 

It  was  not  until  the  second  decade  of  the  nineteenth  century  that  the 
successful  operations  and  lucid  writings  of  Carpue  in  England  and  C. 
Graefe  in  Germany  aroused  the  attention  of  surgeons  to  the  possibil- 
ities of  this  kind  of  work.  These  writers  proved  the  possibility 
of  operative  reconstructions  previously  denied,  and,  by  their  historical 
researches,  showed  that  operators  in  India,  Sicily  and  Italy  had  been 
wont  in  previous  centuries  to  make  new  noses  and  lips  from  the  skin 
of  the  forehead,  arm  or  buttock  for  the  relief  of  facial  disfigurement  due 
to  punitive  mutilation.  It  is  interesting  to  the  English  speaking 
nations  to  known  that  Lucas,  an  Englishman,  learned  frontal  rhino- 
plasty from  Indian  operators  and  practised  it  successfully  before  the 
time  of  Carpue's  book,  and  that,  in  England,  Lynn  in  1803  attempted 
though  unsuccessfully  to  make  a  new  nose  for  a  patient. 

'  De  Curtorum  Chirurgia  per  Institionem.      Venet,  1597. 
^  De  Chirurgicae  Curtorum  possibilitate.     Upsal,  1742. 
^  Dissert.     Qusest.,  An  curtse  Nares  ex  brachio  reficiendse?     Paris,  1742. 

1 


2  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

The  professional  mind  was  directed  to  reconstructive  surgery 
originally,  almost  exclusively  because  unfortunates  with  mutilated 
noses  desired  relief.  It  is  said  that  in  early  times  operations  of  a 
plastic  character  were  done  to  conceal  the  condition  of  those  who  had 
been  circumcised.  It  was  rhinoplastic  operations,  however,  that  gave 
birth  to  a  knowledge  of  the  physiological  possibilities  of  reparative 
surgery. 

In  India,  noses  were  and  are  yet  frequently  cut  off  as  a  punishment. 
Keegan  states,^  that  in  that  country  women  are  frequently  mutilated 
by  husbands  merely  suspicious  of  the  virtue  of  their  wives ;  and  he  gives 
a  table  of  a  very  large  number  of  rhinoplastic  operations  done  within  a 
limited  time  in  the  various  sections  of  the  country. 

It  is  interesting  to  repeat  the  story,  which  has  often  been  told, 
of  the  retribution  visited  by  an  Indian  potentate,  the  King  of  Ghoorka, 
upon  a  conquered  city.  Its  name  was  changed  to  signify  ''The 
City  of  Cut  Noses,"  because  he  cut  off  the  noses  of  all  the  inhabitants, 
except  the  infants  and  those  who  played  wind  instruments.  Similar 
punishments,  though  on  a  less  extended  scale,  were  not  unusual  at  one 
time  in  Europe. 

It  is  not  impossible  that  the  revival  of  plastic  surgery  at  the  end 
of  the  eighteenth  and  the  beginning  of  the  nineteenth  century  was  due 
in  some  degree  at  least  to  non-medical  literature.  The  interest  of  the 
general  public  naturally  centered  in  the  accounts,  scarcely  believed 
even  by  physicians,  of  the  making  of  new  noses,  which  were  said  to 
be  constructed  from  the  forehead,  from  tissues  of  slaves,  or  from  parts 
of  the  body  of  the  patient  distant  from  the  face. 

The  vulgar  allusion  to  Tagliacozzi's  nose  restorations,  made  in 
the  latter  part  of  the  seventeenth  century  in  Hadibras,  shows  that  the 
learned  Butler  was  familiar  with  the  asserted  skill  of  the  illustrious 
Italian  surgeon  of  the  preceding  century;  but  it  was  John  Ferriar, 
litterateur,  as  well  as  doctor  of  medicine,  who  forcibly  called  public 
attention  to  Tagliacozzi's  work  in  his  ''Illustrations  of  Sterne  with 
other  Essays  and  Verses,"  published  in  1798.  Dr.  Ferriar,  who  died 
in  1815,  would  have  read  with  joy  Carpue's  account,  published  in  1816, 
of  two  successful  cases  of  rhinoplasty  in  London;  but  he  died  knowing 
at  any  rate  that  he  had  earnestly  called  the  attention  of  literary  Eng- 
land to  the  importance  of  Tagliacozzi's  original  observations. 

Ferriar  endeavors  to  show  how  Sterne  derived  the  numerous  allusions 
to  the  nose  in  Tristram  Shandy  from  previous  writers,  classic  and  pro- 
fane, and  says,  "  There  is  a  writer  who  deserved  a  higher  place  in  Mr. 
Shandy's  library  than  any  of  those  whom  Sterne  has  ventured  to 

'  Rhinoplastic  Operations.     London,  1900. 


THE  DEVELOPMENT  OF  PLASTIC  SURGERY  3 

mention;  and  he  was  the  more  entitled  to  notice,  because  his  fame 
has  been  unjustly  and  unaccountably  eclipsed."  He  then  devotes 
about  a  dozen  pages  to  quotations  from,  and  abstracts  of,  Taglia- 
cozzi's  book,  "De  Curtorum  Chirurgia." 

His  enthusiasm  is  so  great  that  he  describes  in  considerable  detail 
the  operation  of  rhinoplasty  as  practised  by  the  Bolognese  surgeon, 
and  compares  that  operators's  physiological  deductions  with  those  of 
John  Hunter.  Hunter  had  died  only  five  years  before  the  publication 
of  the  "Illustrations  of  Sterne" ;  and  his  experiments  on  grafting  tissues 
were  evidently  known  to  Farriar.  The  latter  lays  much  stress  upon 
the  fact  that  in  Tagliacozzi's  time  the  arteries  were  supposed  to  be 
full  of  air  and  that  the  circulation  of  the  blood  was  unknown  to  him. 
Hence,  the  Italian  investigator's  views  on  the  method  of,  union  of 
living  parts  are  in  his  estimation  exceedingly  interesting  and  remark- 
ably accurate. 

About  the  time  of  Ferriar's  description  of  brachial  rhinoplasty 
two  other  non-medical  publications  appeared  in  Englan^%-hich  aroused 
public  interest.  They  were  the  "Gentleman's  Magazine^'^'  of  1794  and 
Pennant's  Views  of  Hindostan,  published  about  the  same'  time.  They 
gave  accounts  of  the  construction  of  new  noses  from  the  forehead  per- 
formed in  India  to  relieve  the  horrid  facial  disfigurements  so  common 
in  that  country.  The  "Madras  Gazette"  published  in  Indi^  called  the 
attention  of  the  English  public  to  the  same  subject  at  about  this  time. 

An  almost  universal  disbelief  in  the  availability  of  plastic  operations 
delayed  the  progress  of  this  branch  of  surgery  in  a  very  marked  degree. 
Jobert  says  that  Hiester  denied  even  the  possibility  of  rhinoplasty. 
In  Holmes'  "System  of  Surgery"  plastic  operations  for  the  removal  of 
deformities  clue  to  burns  were  discouraged  by  Coote. 

Prince,  one  of  the  most  earnest  advocates  in  America  of  reparative 
surgery,  said,  "It  is  even  now  (1867)  in  its  infancy  and  is  to  grow  into 
maturity  by  a  better  knowledge  of  general  and  local  therapeutics 
applicable  to  the  healing  of  wounds  and  to  better  conceptions  of 
mechanical  execution." 

This  doubt  of  the  professional  mind  is  a  little  difficult  to  understand, 
when  it  is  remembered  that  there  was  a  considerable  amount  of  litera- 
ture showing  the  possibility  of  the  adhesion  of  parts  entirely  separated 
from  the  body,  if  they  were  reapplied  and  sutured  within  a  reasonable 
time.  Balfour  wrote  in  1814  an  earnest  article  in  the  "Edinburgh 
Medical  and  Surgical  Journal"  asserting  the  possibility  of  the  adhesion 
of  completely  severed  fingers.  He  reported  a  case  in  which  one-half 
of  the  index  finger  which  had  been  completely  cut  off  was  reapplied 
after  an  interval  of  five  minutes  and  became  completely  united  to  the 


4  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

hand.  Zeis  a  little  later  made  a  collection  from  surgical  literature  of 
many  cases  in  which  similar  accidents  had  been  followed  by  union  of 
the  severed  organs.  Probably  the  most  interesting  series  is  that  of 
Hoffacker  who  in  1828  described  sixteen  cases  of  noses,  lips,  and  chins, 
sliced  off  in  duels  at  Heidelberg,  which  had  united  after  reparation. 
One  of  the  cases  reported  by  him  was  remarkable  because  the  ampu- 
tated organ  had  to  be  rescued  from  a  dog  who  had  seized  it;  yet  union 
occurred  after  its  replacement. 

The  belief  in  India  that  cut-off  noses  could  be  successfully  replaced 
is  said  by  Velpeau  to  have  caused  those,  thus  mutilating  criminals 
or  enemies,  to  throw  the  amputated  nose  into  the  fire. 

In  1823  Biinger  in  Marburg  operated  upon  a  woman  who  had  lost 
her  nose  from  lupus.  He  found  it  impossible  to  get  tissue  from  the  face 
and  therefore  cut  a  portion  of  skin  from  the  thigh  and  was  so  fortunate 
as  to  obtain  union.  At  a  later  period  Warren,  of  Boston,  was  success- 
ful in  restoring  small  breaches  of  surface  by  portions  of  skin  cut  entirely 
free  from  their  surroundings. 

These  reports  and  the  stories  that  continued  to  come  from  the 
British  surgeons  in  India  finally  convinced  European  operators  that 
the  restoration  of  distorted  features  and  useless  limbs  had  been  a 
aegiected  department  of  surgery.  The  German  and  French  writers 
became  very  enthusiastic  in  practising  and  urging  a  resort  to  plastic 
measures.  American  surgeons,  largely  through  Mutter's  influence, 
followed  in  their  steps.  Roux  thought  that  there  was  almost  nothing 
impossible  in  the  restoration  of  the  face.  He  said  that  in  plastic  sur- 
gery very  many  and  signal  services  had  been  rendered  in  improving 
the  appearance  of  the  human  face,  integrity  of  which  was  of  so  much 
importance  for  the  exercise  of  the  senses  and  for  "  the  needs  and  amen- 
ities of  social  life." 

Jobert  was  so  carried  away  with  enthusiasm  that  he  said  the  prog- 
ress of  plastic  surgery  would  in  the  future  be  considered  "  one  of  the 
most  beautiful  conquests  of  the  surgery  of  the  nineteenth  century." 
He  adds  "  The  artist  should  be  above  all  things  the  savant  who  know^s 
all  the  laws  of  vital  reaction,  the  physician  who  foresees  every  cause 
of  accident,  and  who  knows  how  to  act  under  all  conditions  which 
present  themselves."  This  opinion  of  the  necessity  of  deftness  in  the 
operator,  who  essays  plastic  restorations,  is  also  indicated  in  the  words 
with  which  Phillips  describes  the  instruments  used  by  Dieffenbach, 
which  were  so  small  that  they  "looked  as  if  intended  for  making  lace 
rather  than  working  with  large  portions  of  living  tissue." 

It  is  not  necessary  for  us  at  this  time  to  go  into  a  discussion  of  the 
various  names  which  were  given  by  these  writers  to  that  Avhich  we  now 


THE  DEVELOPMENT  OF  PLASTIC  SURGERY  5 

call  plastic  or  reparative  surgery.  The  term  plastic  surgery,  was,  I 
believe,  first  suggested  by  Zeis,  and  it  has  displaced  to  a  great  extent 
autoplasty,  anaplasty  and  other  suggested  terms. 

Delpech,  Dieffenbach,  Labat,  Blandin,  Serre,  von  Ammon, 
Jobert  and  Zeis  continued,  during  the  first  half  of  the  nineteenth 
century,  the  work  of  popularizing  plastic  surgery  and  extending  its 
domain.  Zeis's  ''Manual  of  Plastic  Surgery,"  pubhshed  in  Berlin  in 
1838,'  is  a  systematic  and  scholarly  treatise  on  the  subject.  It  collected 
and  made  available  for  study  most  of  that  which  had  been  previously 
written.  About  this  time  the  method  of  employing  skin  without  a 
pedicle  for  making  the  new  nose  was  also  adopted  in  a  limited  number 
of  cases.  The  tissue  was  usually  taken  from  the  buttock  of  the  patient 
himself  and  applied  to  the  freshened  edges  of  the  nasal  stump.  Biin- 
ger  appears  to  have  been  the  only  European  operator  who  was  success- 
ful in  the  use  of  this  method.^  This  forerunner  of  Krause's  method  of 
implanting  flaps  without  pedicles  shows  the  probability  that  asepsis 
was  occasionally  obtained  accidentally  by  our  surgical  predecessors. 

In  1837  or  1838  there  was  published  in  the  ''American  Journal  of 
Medical  Sciences"  an  article  on  "Cases  of  Autoplastie,"  detailing  operaT 
tions  for  cicatricial  deformity  of  the  mouth  and  for  loss  of^  the  wing 
of  the  nose.  The.  author-  and  successful  surgeon  was  a  recent 
graduate,  named  Thomas  D.  Mutter,  who  was.  destined  to  achieve 
fame  in  American  surgery. 

In  July,  1842,  there  appeared  in  the  same  periodical  an  article  on 
"Cases  of  Deformity  from  Burns  successfully  treated  by  Plastic 
Operations"  by  the  same  Thomas.  D.  Mutter,  who  wrote  a  number  of 
other  papers  about  this  time  on  allied  topics.  About  the  same  time 
Joseph  Pancoast  of  Philadelphia  and  J.  Mason  Warren  of  Boston 
published  clinical  reports  of  operations  for  the  repair  of  nasal  and  other 
facial  deformities  by  means  of  displaced  integument.  These  three 
surgeons  are  therefore  entitled  to  the  credit  of  introducing  reparative 
methods  into  American  surgery.  Mutter  modestly  mentions  his 
own  connection  with  the  movement  and  truthfully  says  that  Warren 
"was  probably  the  first  to  introduce  the  successful  application  of  plastic 
surgery  in  the  United  States."^  Post,  Buck,  Andrews  and  Prince 
took  much  interest  in  advocating  in  America  this  branch  of  operative 
surgery  and  devised  additional  methods  of  untilizing  its    principles. 

This  brief  historical  review  shows  the  potent  influence  that  Mutter, 
exercised  in  the   development   of   a  most  important   department   of 

'"Journal  fUr  Chir.  und  Augenheilkunde"  (von  Graefe  und  von  Walther)  iv, 
569. 

^  Introductory  Lecture,  Jefferson  Medical  College,  1842. 


6  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

surgery;  the  benefits  of  which  are  to-day  evident  in  the  treatment  of 
not  only  facial  disfigurements,  but  gynecological,  orthopedic  and 
general  surgical  lesions. 

The  important  part  played  in  the  world's  surgery  by  the  plastic 
operations  of  Mutter  and  his  colleagues  in  America  is  seen  by  reading 
the  words  of  European  writers.  Sir  William  Fergusson  in  writing  on 
cleft  palate  in  1864^  said:  "In  as  far  as  I  know,  the  greatest  success 
recorded  before  my  own  views  were  made  public  was  that  achieved  by 
Mutter  of  Philadelphia.  In  1843  he  had  operated  successfully  nineteen 
out  of  twenty-one  cases."  Szymanowski,  whose  "Manual  of  Operative 
Surgery' '  is  largely  devoted  to  a  systematic  exposition  of  plastic  methods 
in  surgery,  refers  in  his  preface  to  the  fact  that  in  1867  English  authors 
were  less  acquainted  than  American  surgeons  with  the  progress  of 
reparative  surgical  science. 

It  is  a  little  difficult  at  the  present  time  to  realize  the  great  influence 
exerted  by  Mutter,  Pancoast  and  Warren  in  a  then  comparatively 
undeveloped  field.  The  frequent  references  in  European  literature 
of  the  time  to  Mutter's  cases  surprised  me,  when  I  first  read  them. 
It  evidently  was  difficult  for  many  to  believe  that  displaced  tissue 
would  satisfactorily  assume  the  functions  expected  of  it  in  its  new 
situation.  It  required  ocular  demonstrations  at  the  hands  of  original 
and  energetic  men  like  Mutter  to  convince  the  incredulous.  He 
himself  says  in  his  introductory  lecture  on  "Recent  Improvements 
in  Surgery"  that  such  operations  had  been  ridiculed  by  Butler, 
Voltaire  and  Addison,  and  that  "even  now,  notwithstanding  the  positive 
testimony  of  the  first  authorities  in  their  favor,  are  supposed  by 
many  to  be  bare  assertions,  destitute  of  truth,  and  as  useless  as  they 
are  apochryphal." 

The  Russian  surgeon,  Szymanowski,  in  1867  made  an  elaborate 
attempt  to  sytematize  the  various  operative  procedures  for  the  relief 
of  deformities  requiring  plastic  surgery.  In  his  "Manual  of  Operative 
Surgery"  he  devotes  many  pages  to  illustrations  showing  the  principles 
upon  which  the  integuments  can  be  satisfactorily  displaced.  His 
experiments  on  the  cadaver  aided  him  very  much  in  the  preparation 
of  this  portion  of  his  book,  which  is  a  classic. 

A  decided  step  in  advance  was  made  in  1871  by  Reverdin,^  who 
proposed  what  is  called  skin  grafting,  or,  better,  epidermic  grafting, 
for  covering  ulcers  and  granulating  wounds.  At  about  the  same  time 
Hanff  also  made  the  discovery  that  small  particles  of  skin  and  epider- 
mis placed  upon  granulating  surfaces  would  serve  as  centers  of  cicatri- 

1  Lancet,  June  25,  1864,  p.  723. 

2  Gaz.  med.  de  Paris,  1873,  3  S,  xxvi,  544, 


THE  DEVELOPMENT  OF  PLASTIC  SURGERY  7 

zation.  This  method  of  skin  grafting  caused  healing  of  ulcerated 
surfaces  previously  considered  incurable.  It  also  hastened  the  time 
of  cicatrization  in  other  ulcers  by  lessening  the  contraction  due  to 
the  formation  of  a  large  amount  of  young  fibrous  tissue.  It  is  now- 
well  known  that  extensive  areas  of  tissue  will  become  covered  with 
cicatricial  skin  without  much  contraction,  if  healing  can  be  completed 
quickly  and  without  the  growth  of  much  granulation  tissue. 

Other  steps  in  the  progress  of  reparative  surgery  were  the  announce- 
ment by  Thiersch^  in  1886  of  his  method  oi  transplanting  large  shavings 
of  the  upper  layers  of  the  skin.  Some  time  previously  Wolfe,  the 
ophthalmic  surgeon  of  Glasgow,  had  showed  that  moderate  size  pieces 
of  skin  could  be  transplanted  without  a  pedicle  with  comparative 
certainty  of  union.  His  restoration  of  deformed  eyehds  was  of  great 
value  in  stimulating  the  study  of  plastic  methods. 

Hiiter  even  went  so  far  as  to  use  hairy  flaps  after  the  Wolfe  method 
for  the  repair  of  eyebrows.  The  osteoplastic  operations  of  Oilier  showed 
that  even  raw  surfaces  of  bone  would  unite.  Within  later  years  the 
closing  of  a  trephine  opening  in  the  skull  by  replacing  the  disk  of  bone, 
the  substitution  of  a  portion  of  fibula  for  a  gap  in  the  tibia,  the  splitting 
of  a  bone  into  two  parts  so  as  to  make  two  distinct  bones,  and  the  nailing 
or  suturing  of  bone  flaps  in  new  positions  have  resulted  from  Oilier' s 
experiments  and  widened  the  field  of  reconstructive  surgery. 

Krause  has  so  improved  the  use  of  grafts,  or  flaps  of  skin  without 
pedicles,  that  it  is  even  possible  to  amputate  a  limb  and  cover  the 
structures  with  skin  taken  from  other  portions  of  the  body  or  from  the 
discarded  leg  or  arm. 

Muscles  are  now  sutured  so  as  to  substitute  muscles  torn  away 
by  accident,  or  paralyzed;  and  nerve  trunks  are  transferred  to  new 
positions  in  order  to  assume  new  functions.  A  fatty  tumor  extir- 
pated from  the  thigh  has  been  used  by  Czerny,  it  is  said,  to  give  a 
normal  appearance  to  a  mammary  gland  from  which  an  undesirable 
tumor  had  previously  been  taken.  Gluck  succeeded  experimentally 
in  repairing  a  defect  in  the  carotid  artery  by  patching  that  vessel  with 
a  piece  of  the  jugular  vein." 

Ankylosed  joints  have  been  made  permanently  mobile  by  inserting 
flaps  of  fascia  between  the  ends  of  their  constituent  bones. ^ 

Grafts  from  amputated  limbs  and  cadavers  have  been  emploved 
successfully;   and    Vanlair  has  even  suggested,  according  to  Gluck, 

^  Verhand.  der  deutsch.  Gesell.  fiir  Chirurgie,  1886,  v.  17. 
2  Verhand.  d.  Congres  f.  inn.  Med.,  1898,  xvi,  384,  385. 

^Ankylosis.  Arthroplasty — Clinical  and  Experimental.  By  John  B.  Murphy, 
"Transactions  American  Surgical  Association,"  xxii,  p.  315. 


8  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

that  perhaps  it  is  not  impossible  to  take  portions  of  organs  at  the 
moment  of  death,  or  possibly  whole  organs,  and  use  them  for  the 
restoration  of  internal  parts.  The  thyroid  gland  of  the  sheep  has 
within  recent  years  been  implanted  in  the  abdomen  of  man  to  act 
as  a  substitute  for  his  diseased  or  extirpated  thyroid  gland.  The 
ovary  has  been  transplanted  successfully  from  one  animal  to  another 
and  from  one  region  to  another  region  in  the  same  animal;  and  is  said 
to  carry  on  its  function  so  that  pregnancy  can  occur.  ^  This  is  an 
indication  of  the  belief  in  some  professional  minds  of  the  availability 
of  such  substitutive  actions.  Nicoladoni  has  recommended  for  the 
loss  of  the  thumb,  the  grafting  of  a  second  toe  upon  the  hand,  and 
has  done  this  operation. 

The  successes  of  Payr,  Hoepfner,  Carrel,  Garre,  Guthrie  Morestin 
and  Lexer  in  experimental  and  clinical  plastic  operations  have  greatly 
widened  this  field  of  surgery.  Arterial  and  venous  suturing  have 
become  accepted  procedures.  Blood-vessels  may  be  patched  after 
injury.  Masses  of  bone  may  be  used  to  repair  the  osseous  structures. 
Aseptic  grafts  may  even  be  used  with  success  after  preservation  in 
cold  storage  for  a  number  of  days;  because  the  latent  life  is  preserved.^ 

Gluck  urges  the  introduction  of  foreign  materials  into  the  tissues 
to  remain  there  permanently  and  act  as  substitutes  for  the  normal 
structures.  The  use  of  a  glass  ball  to  represent  the  vitreous  humor  in 
an  eviscerated  eye,  as  proposed  by  Mules,  has  been  employed  by  many 
surgeons  with  success.  Paraffin  moulded  into  shape,  celluloid  and> 
metal  supports  have  been  worn  within  the  tissues  of  the  nose  and  else-- 
where  for  many  years  without  giving  trouble,  and  substitutes  of  simi- 
lar materials  have  been  placed  in  the  scrotum  to  represent  the  testicles 
and  relieve  mental  distress  at  the  loss  of  these  organs.  It  is  possible 
that  this  "implantation-therapy"  of  Gluck  is  susceptible  of  far  greater 
use  and  development  than  is  yet  realized. 

At  the  present  time  anesthesia  permits  our  operative  work  to  be 
prolonged;  and  our  methods  of  restraining  hemorrhage  and  preventing 
infection  make  the  risk  of  operative  treatment  scarcely  worthy  of 
consideration.  Under  the  opposite  circumstances  it  must  have  taken 
men  of  great  courage  and  mental  force  to  have  urged  patients  to  under- 
go operations  which  were  clearly  procedures  of  convenience  and  not  of 
necessity. 

^  Surgery,  Gynaecology  and  Obstetrics,  July,  1911,  p.  53,  Deutsch  Zeitsch.  flir 
Chirurgie,  99.  Bd.  1-2  Hft. 

^Keen's  Surgery,  vol.  v.,  p.  884.     Archiv.  fur  klin.  Chirurgie,  83.  Bd.  2  Hft. 


CHAPTER  II. 
A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE. 

In  the  present  study,  the  face  includes  more  than  that  which 
is  called  the  face  in  a  strict  anatomical  sense.  The  frontal  and  tem- 
poral regions  of  the  cranium  must  be  included.  The  disfigurements 
which  are  to  be  considered  concern  the  ears  and  the  forehead  as  well 
as  that  portion  of  the  head  usually  called  the  face  in  anatomical 
treatises.  The  bones  and  soft  tissues  of  the  region,  the  surgery  of 
which  is  to  be  discussed,  need  not  be  minutely  described ;  but  a  general 
view  will  be  valuable.  Good  surgery  of  any  region  of  the  body  is 
impossible  without  a  knowledge  of  the  bony  landmarks  and  the 
mutual  relations  of  the  soft  parts.  The  blood  supply  and  the  location 
of  the  important  nerve  trunks  and  ducts  are  topics  of  special  interest. 

If  the  face  is  looked  at  from  in  front,  it  is  bounded  laterally  above 
by  the  bulge  of  the  parietal  bones,  behind  the  coronal  suture,  and  by 
the  anterior  part  of  the  squamous  portion  of  the  temporal  bones.  The. 
narrowest  part  of  the  forehead  lies  between  the  temporal  crests  or 
ridges,  about  half  an  inch  above  the  external  angular  process.  This 
is  situated  at  the  upper  and  outer  part  of  the  orbit.  The  lower 
part  of  the  face,  the  shape  of  which  is  determined  by  the  form  of  the 
mandible,  or  lower  jaw,  is  bounded  below  by  the  upper  portion  of 
the  throat  and  neck.  This  region  also  is  of  importance  in  the  plastic 
surgery  of  the  face,  because  the  soft  tissues  of  the  throat  and  neck 
are  often  used  in  reconstructive  operations  about  the  mouth. 

In  this  hasty  survey  it  will  perhaps  be  sufficient  to  call  attention 
to  only  a  few  of  the  most  prominent  anatomical  features  of  the  bony 
skeleton.  Across  the  frontal  bone  and  below  the  frontal  eminences 
will  be  observed  two  transverse  furrows,  which  are  just  above  the  super- 
ciliary ridges.  Below  these  ridges  are  situated  the  supraorbital  arches 
which  form  the  upper  margin  of  the  eye  sockets.  They  show  at 
about  one-half  inch  from  their  inner  end  the  supraorbital  notches, 
or  foramina,  through  which  pass  the  supraorbital  nerve  and  vessels. 
The  situation  of  this  notch  and  the  artery  coming  through  it  have  an 
important  bearing  upon  the  position  of  the  pedicle  of  the  flap  in 
frontal  rhinoplasty.  A  well-known  landmark  is  the  glabella,  the 
smooth  surface  in   the  middle   line  just  above   the  depression   made 

9 


10  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

by  the  junction  of  the  frontal  bone  and  the  nasal  bones.  The  mid- 
point of  the  suture  between  the  frontal  bone  and  the  nasal  bones  is 
called  the  nasion. 

Very  conspicuous  are  the  two  eye-sockets  which,  somewhat  quad- 
rilateral in  shape,  have  rounded  margins  of  very  compact  bone. 
These  margins  are  formed  by  the  frontal,  malar,  and  superior  maxil- 
lary bones.  The  situation  of  the  lachrymal  gland  underneath  the 
upper  and  outer  angle  of  the  orbital  margin  should  be  recollected; 
and  the  groove  for  the  lachrymal  sac  at  the  inner  and  lower  angle  must 
not  be  forgotten  by  the  operating  surgeon.  The  infraorbital  foramen, 
through  which  pass  the  infraorbital  nerve  and  vessels,  lies  about  a 
quarter  of  an  inch  below  the  lower  orbital  margin,  and  almost  vertically 
above  the  second  bicuspid  tooth.  Ocasionally  there  are  two  openings 
here;  probably  because  the  vessels  and  nerve  do  not  always  come 
through  the  same  foramen. 

The  pyriform  aperture  of  the  nasal  chambers,  below  and  between 
the  orbits,  is  in  shape  like  an  inverted  ace  of  hearts.  Its  long  axis 
is  vertical  and  its  margins,  formed  by  the  two  nasal  and  two  superior 
maxillary  bones,  has  a  rather  sharp  and  easily  broken  edge.  The 
prominent  nasal  spine  below  for  the  attachment  of  the  columella 
is  of  some  surgical  importance.  In  the  skeleton  there  is  seen  within 
the  nasal  aperture  the  anterior  edge  of  the  osseous  nasal  septum. 
It  is  made  up  of  the  vomer  below  and  the  nasal,  or  vertical,  lamella 
of  the  ethmoid  bone  above.  The  nasal  aperture  is  much  contracted 
by  the  nasal  cartilages,  which  form  the  basis  of  the  projecting  portion 
of  the  nose.  A  clear  understanding  of  the  cartilaginous  attachments 
an4  of  the  influence  of  the  bony  and  cartilaginous  septum  of  the  nose 
upon  its  shape  are  essential  to  successful  plastic  work  upon  this  organ. 
Many  very  unsightly  deformities  of  the  face  are  due  to  inefficient 
treatment  of  nasal  fractures.  The  anterior  portion  of  the  inferior 
turbinal  bone  is  seen  by  looking  into  the  anterior  nostrils. 

The  malar  bone,  which  makes  the  prominence  of  the  cheek  and  which 
behind  is  attached  to  the  zygoma  of  the  temporal  bone,  has  a  great 
deal  to  do  with  the  shape  of  the  face,  as  the  configuration  of  the  cheek 
depends  greatly  upon  it.  In  its  normal  configuration  it  varies  much 
in  different  races.  This  can  be  easily  appreciated  by  comparing  the 
face  of  the  North  American  Indian  with  that  of  an  individual  of  the 
yellow  or  the  white  race. 

The  manner  in  which  the  malar  bone  assists  in  making  the  arch 
spanning  the  temporal  fossa  is  the  cause  of  the  unseemly  deformity, 
which  arises  when  blows  in  this  region  crush  in  the  arch.  Elevation 
of  the  broken  bone  is  an  exceedingly  simple  operation,  and  yet  is 


A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE  11 

not  always  performed  after  the  receipt  of  such  injuries.  The  crush- 
ing of  the  anterior  wall  of  the  hollow  upper  jaw  creates  another  de- 
formity of  a  similar  kind,  which  is  sometimes  allowed  to  cause  per- 
manent disfigurement  by  being  unscientifically  treated. 

The  upper  jaw  is  a  bone  of  major  importance  in  the  construction 
of  the  face,  for  it  takes  part  in  forming  the  walls  of  the  orbit,  the 
nose  and  the  mouth.  Its  alveolar  arch  must  correspond  with  the 
same  portion  of  the  lower  jaw  in  such  a  way  that  the  upper  teeth  may 
lie  in  front  of  the  lower  teeth  when  the  mouth  is  closed.  The  incisive 
portions  of  the  two  upper  jaw  bones  are  developed  by  special  centers 
of  ossification.  They  therefore  have  much  to  do  with  the  deformities 
of  the  lower  portion  of  the  face  and  mouth.  Harelip  and  cleft  palate 
are  the  most  conspicuous  and  commonly  recognized  congenital  de- 
formities due  to  improper  development  of  this  portion  of  the  facial 
skeleton.  In  some  cases  of  double  harelip  there  exists  a  projecting 
prominence  of  bone,  because  the  premaxillary  elements  of  the  incisive 
region  fail  to  unite  with  the  rest  of  the  upper  jaw. 

A  most  conspicuous  deformity  is  that  in  which  the  lower  jaw 
with  its  teeth  project  in  front  of  the  upper  jaw.  This  deformity 
is  said  to  be  due  at  times  to  a  precocious  ossification  of  the  sutures 
between  the  body  of  the  upper  jaw  and  the  incisive  or  intermaxillary 
portions.  As  a  result,  the  upper  jaw  and  the  teeth  belonging  to  it 
do  not  develop  in  a  forward  direction  as  much  as  they  ought  and  the 
lower  jaw  consequently  gains  an  undue  prominence.  It  thus  alters 
the  shape  of  the  lower  segment  of  the  face.  The  proper  understanding 
of  the  cause  of  the  deformity  will  prevent  many  children  from  becoming 
conspicuously  uncomely.  Mechanical  appliances  may  be  used  by  the 
dental  surgeon  to  prevent  the  impending  ugly  alteration  in  the  relation 
of  the  two  jaws. 

The  mandible,  or  lower  jaw,  gives  form  to  the  lower  part  of  the 
face  and  to  a  certain  extent  the  cheeks.  It  is  one  of  the  most  important 
of  the  bony  elements  of  the  face  and  has  an  exceedingly  great,  direct 
and  indirect,  influence  upon  the  appearance  of  the  individual. 

The  chin  or  mental  process  is  often  marked  by  a  median  notch, 
on  each  side  of  which  is  a  blunt  swelling  or  tubercle.  From  this 
ascends  an  oblique  line  to  meet  its  fellow  of  the  other  side  below  the 
sockets  of  the  incisor  teeth.  An  external  oblique  line  runs  backward 
from  the  mental  tubercle  to  the  level  of  the  last  molar  tooth.  Above 
this  line  and  below  the  second  pre-molar,  or  biscuspid,  tooth  is  the  men- 
tal foramen  through  which  passes  the  mental  nerve  and  vessels.  It  is 
said  that  the  lower  jaw  has  a  special  tendency  to  become  necrotic, 
because  its  arterial  supply  depends  upon  the  integrity  of  the  two  mental 


12  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

arteries.  The  other  bones  of  the  face  are  particularly  well  supplied 
with  blood  because  of  the  large  number  of  vessels  running  into  them. 
The  groove  for  the  facial  artery,  found  at  the  lower  edge  of  the  mandi- 
ble in  front  of  the  attachment  of  the  massenter  muscle,  is  a  landmark 
of  importance.  Temporary  pressure  can  be  made  upon  the  artery  at 
this  point  to  lessen  the  bleeding  in  operations  upon  the  face. 

The  angle  between  the  body  of  the  lower  jaw  and  its  ascending 
ramus  varies  greatly  in  different  individuals  and  at  different  ages. 
It  is  very  obtuse  in  infants  and  much  nearer  the  right  angle  in  adult 
males.  The  angle  is  more  obtuse  in  women  than  in  men.  In  the 
adult  male  it  is  about  122°.  Changes  in  the  angle  of  the  jaw  and  the 
prominence  of  the  chin,  produced  by  the  loss  of  the  teeth  and  the  ab- 
sorption of  the  alveolus  in  old  age,  give  the  characteristic  appearance 
to  the  senile  face.  This;  may  be  prevented  by  the  early  adoption  of 
artificial  dentures. 

Medical  men  as  a  rule  pay  too  little  attention  to  the  influence  of  a 
proper  development  of  the  teeth  upon  the  shape  of  the  mouth,  chin 
and  the  Lower  face.  While  the  facial  angle,  studied  by  Camper  and 
others,  has  been  a  subject  of  interest  to  physicians  as  well  as  to  artists, 
the  influence  of  the  teeth  and  jaws  upon  personal  comeliness  has  been 
almost  entirely  overlooked  in  medical  practice. 

Anchylosis  of  the  temporo-maxillary  joint,  preventing. movement 
of  the  lower  jaw,  will,  if  occurring  in  childhood,  lead  to  atrophy  or 
want  of  proper  development  of  the  bone.  As  a  result  the  patient, 
grows  up  with  an  immature  chin  which  causes  very  conspicuous  dis- 
figurement. Burns  of  the  lower  part  of  the  face  and  of  the  neck  will 
prevent  proper  mobility  of  the  mandible  and  lead  in  growing  children 
to  a  lengthening  and  bending  downward  of  the  front  of  the  lower 
jaw  bone.  Persistent  thumbsucking  in  young  children,  after  the 
second  dentition,  causes  deviation  of  the  teeth,  particularly  of  the 
upper  jaw,  and  therefore  an  abnormal  relation  of  the  upper  and  lower 
jaw  bones. 

A  lateral  view  of  the  region  under  consideration  shows,  in  the 
upper  portion,  the  anterior  part  of  the  curved  temporal  ridge,  or 
crest,  where  it  runs  into  the  external  angular  process  of  the  frontal 
bone.  This  bony  prominence  extends  downward  to  join  the  corre- 
sponding process  of  the  malar,  or  cheek,  bone  which  bounds  the  tem- 
poral fossa  in  front.  At  right  angles  to  the  base  of  this  anterior  wall 
of  the  temporal  fossa  and  extending  backward  is  the  zygomatic  arch, 
made  by  contiguous  processes  of  the  malar  and  temporal  bones. 

In  front  and  above  the  temporal  crest  are  seen  the  bulging  frontal 
prominences  which  constitute  the  forehead.     These  frontal  eminences 


A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE  13 

are  better  marked  in  young  persons  and  in  women  than  in  adult  males. 
Beneath  the  frontal  prominences  is  seen  the  shallow  transverse  furrow 
of  the  forehead.  Beneath  this  are  the  superciliary  ridges,  forming  the 
lower  limit  of  the  forehead,  and  the  supraorbital  arches  which  consti- 
tute the  upper  limits  of  the  eye  sockets.  The  superciliary  ridges  are 
directed  obliquely  upward  and  outward  and  are  better  marked  in  the 
adult,  because  the  frontal  sinuses,  or  air  cavities,  beneath  them 
develop  with  the  increasing  age  of  the  child.  It  is  this  increased 
prominence  of  the  superciliary  ridges,  due  to  the  frontal  sinuses 
within,  that  makes  the  frontal  eminences  relatively  smaller  in  the 
adult  male  than  in  women  and  children.  The  frontal  sinus  begins 
to  develop  at  about  seven  years  of  age. 

The  point  where  the  temporal  crest  crosses  the  coronal  suture  is 
called  the  stephanion.  The  temporal  fossa  in  which  lies  the  tem- 
poral muscle,  covered  by  the  temporal  fascia,  is  in  many  faces  indi- 
cated by  a  marked  depression.  This  is  particularly  the  case  in  persons, 
who  are  lean.  The  emaciation  of  illness  is  often  the  cause  of  a  great 
change  in  the  face  because  of  the  absorption  of  fat  in  this  fossa.  A 
full  appreciation  of  the  construction  of  the  zygomatic  arch  is  necessary 
for  the  proper  treatment  of  deformities  in  the  temporal  region.  When 
the  bones  are  covered  by  the  temporal  muscle  and  other  soft  tissues, 
the  importance  of  maintaining  a  proper  relation  of  the  bony  frame- 
work may  be  overlooked.  Fractures  here  cause  great  deformity, 
which  is  easily  overcome  by  elevating  the  broken  bone  so  as  to  re- 
construct the  normal  curve  of  the  arch. 

A  study  of  the  lower  portion  of  the  side  of  the  face  makes  it  at 
once  evident  that  the  lower  jaw  is  the  essential  bony  element.  Upon 
the  proper  development  of  the  teeth  depends  the  shape  of  the  lower 
jaw  and  therefore  the  configuration  of  the  lower  part  of  the  face. 
This  question  has  been  discussed  in  the  remarks  made  in  regard  to 
the  appearance  of  the  face  from  in  front.  The  shape  of  the  angle 
of  the  jaw  and  the  manner  in  which  the  cheek  is  formed  by  the  malar 
bone  and  ascending  ramus  of  the  jaw  are  apparent,  when  the  face  is 
examined  on  its  lateral  aspect.  The  deviations  in  the  prominence 
of  the  nasal  bones  and  the  attached  soft  parts  in  front  are  usually 
observed  much  better  when  the  face  is  studied  from  the  side  than  from 
in  front.  The  goniometer  of  Camper  has  been  employed  to  measure 
the  facial  angle  which  varies  greatly  in  the  different  races  of  man  and 
in  different  types  of  the  same  race. 

There  are  certain  of  the  soft  tissues  of  the  face  which  deserve 
special  attention  bj^  the  surgeon  operating  in  this  region.  The 
foramina  for  the  exit  of  the  terminal  branches  of  the  three  divisions  of 


14  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

the  fifth,  or  trifacial;  nerve  have  passing  through  them  the  corre- 
sponding arteries  and  veins.  The  situation  of  these  vessels  is  im- 
portant, because  flaps  should  be  cut  so  as  to  maintain  when  possible 
the  integrity  of  these  nerves  and  vessels.  Injury  of  these  nerves 
usually  is  not  of  grave  importance  because  the  lesion  produces  merely 
a  paralysis  of  sensation,  which  may  be  only  temporary.  Division  of 
the  artery  may  in  some  cases  lead  to  sloughing  of  an  important  part  of 
the  flap.  This  is  not  of  very  common  occurrence,  because  of  the  rich 
anastomosis  of  vessels  in  the  facial  tissues. 

The  supraorbital  foramen  is  situated  at  about  the  juncture  of  the 
inner  third  with  the  middle  third  of  the  supraorbital  arch.  A  line 
drawn  from  this  point  downward  and  slightly  outward,  so  as  to  cross 
the  space  between  the  two  bicuspid  teeth  in  the  upper  and  lower 
jaws,  passes  over  the  infraorbital  and  the  mental  foramina. 

The  seventh,  or  facial,  nerve,  which  is  the  motor  nerve  of  the 
muscles  of  expression,  makes  its  exit  from  the  stylo-mastoid  foramen, 
passes  through  the  parotid  gland,  and  breaks  up  into  branches  which 
radiate  toward  the  temple,  the  eye,  the  cheek  and  the  lower  jaw.  Its 
existence  in  this  region  should  not  be  forgotten,  because  incisions  made 
transverse  to  its  branches  are  liable  to  divide  it  and  cause  permanent 
disfiguring  paralysis  of  muscles.  The  manner  in  which  its  branches 
radiate  from  behind  and  beneath  the  lobe  of  the  ear  should  be  remem- 
bered. Immediately  behind  the  posterior  margin  of  the  ascending 
ramus  of  the  lower  jaw  is  the  external  carotid  artery,  a  structure  to  be 
carefully  avoided  when  operating  between  the  ear  and  jaw. 

The  temporal  artery,  which  is  one  of  the  terminal  branches  of  the 
external  carotid,  extends  upward  between  the  root  of  the  zygoma 
and  the  ear  and  then  divides  in  the  temporal  region  into  an  anterior 
and  a  posterior  branch.  These  branches  are  easily  seen  under  the 
skin  of  the  forehead. 

The  transverse  facial  artery,  arising  from  the  temporal,  runs 
forward  upon  the  cheek  from  in  front  of  the  auditory  meatus  toward 
the  mouth. 

The  facial  artery,  which  is  a  branch  of  the  external  carotid  in  the 
neck,  passes  over  the  lower  border  of  the  jaw  at  the  anterior  margin 
of  the  masseter  muscle.  It  runs  obliquely  upward  to  the  angle  of  the 
mouth,  passes  along  the  side  of  the  nose,  and  terminates  at  the  inner 
canthus  of  the  eye,  where  it  is  called  the  angular  artery.  From  it 
arise  the  coronary  arteries  which  supply  the  lips  and  are  felt  im- 
mediately under  the  mu€Ous  membrane.  The  facial  vein  does  not 
accompany  the  tortuous  artery,  but  runs  more  directly  from  the 
inner  angle  of  the  eye  to  the  front  of  the  masseter  muscle.     The  facial 


A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE  15 

artery  can  be  felt  and  compressed,  where  it  crosses  the  border  of  the 
mandible,  and  also  from  within  the  mouth,  where  it  lies  under  the 
mucous  membrane  near  the  corner  of  the  mouth. 

A  very  important  structure  which  must  be  avoided  in  incisions 
upon  the  face  is  the  duct  of  the  parotid  gland.  It  is  a  firm  white 
tube  about  the  size  of  a  goose  quill.  It  runs  parallel  to  and  below  the 
zygoma,  on  a  line  drawn  from  the  base  of  the  lobe  of  the  ear  to  a  point 
midway  between  the  ala  of  the  nose  and  the  angle  of  the  mouth. 
About  the  middle  of  this  line,  it  dips  suddenly  inward  around  the 
front  of  the  masseter  muscle,  and  penetrates  the  fat  and  the  buccinator 
muscle  to  enter  the  mouth  opposite  the  second  molar  tooth  of  the 
upper  j  aw. 

The  parotid  gland,  filling  the  irregular  space  between  the  mastoid 
process  and  the  auricle  behind  and  the  ramus  of  the  jaw  in  front, 
should  be  remembered.  Incisions  into  it,  however,  usually  do  little 
harm  unless  the  duct  of  Stenson,  already  mentioned,  or  one  of  its  larger 
branches  is  injured.     A  salivary  fistula  is  then  likely  to  be  produced. 

The  eyebrows  and  eyelids  are  important  structures  because  in- 
cisions or  wounds  may  make  conspicuous  blemishes,  unless  carefully 
repaired  by  suturing.  The  size  of  the  palpebral  fissure  has  a  great 
influence  in  making  the  eyes  look  large  or  small.  The  eyeballs 
vary  very  little  in  size,  but  a  narrow  fissure,  as  in  the  Chinese  race, 
makes  the  eye  seem  very  small. 

The  lachrj^mal  puncta,  which  are  seen  as  two  little  black  dots  on  the 
edge  of  each  lid  near  the  inner  angle  of  the  eye,  lie  close  to  the  ball  so  as 
to  catch  the  tears  which  wash  the  surface  of  the  eye.  Any  eversion 
of  this  portion  of  the  eyelid  due  to  cicatricial  contraction  will  cause  a 
continual  overflow  of  tears.  The  surgeon's  incisions  must  be  made 
so  as  to  avoid  the  production  of  this  everted  condition.  Care  must 
also  be  taken  to  avoid  wounding  the  lachrymal  sac  at  the  inner  angle 
of  the  eye  lying  underneath  the  tendo  oculi. 

The  attachments  of  the  nasal  and  aural  cartilages  and  their  general 
shape  should  be  familiar  to  operators.  The  varieties  in  shape  of  the 
nose  and  ear  are  very  great  and  will  often  require  surgical  interference 
for  their  modification.  It  is  not  unusual  to  find  the  details  in  the 
shape  of  the  auricle  different  on  the  two  sides.  This  variation  is  not 
very  important,  because  both  ears  are  not  apt  to  be  critically  observed 
at  the  same  time. 

A  study  of  the  soft  parts  of  the  lips  and  the  mouth  shows  that 
there  is  great  variation  here  also.  The  mobiHty  of  the  lips  is  extreme, 
though  there  is  a  certain  amount  of  fixedness  in  the  middle  line.  The 
orbicular  muscle  of  the  mouth  forms  the  bulk  of  the  lips.     It  may 


16 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


be  subjected  to  many  operative  procedures  without  the  occurrence 
of  much  deformity,  provided  that  the  relation  between  the  Hps  them- 
selves and  between  them  and  the  other  features  is  maintained.  A 
want  of  balance  due  to  operation  or  injury  may  make  a  very  conspic- 
uous deformity  which  a  restoration  of  the  relative  proportions  will 
overcome. 

Surgeons  and  medical  men  in  general  have  very  little  conception 
of  the  importance  of  the  teeth  in  the  physical  conformation  of  the 
face  and  the  expression  of  the  individual.  Many  persons  suffer  a 
very  great,  though  unnecessary  uncomeliness,  because  the  teeth  have 
been  allowed  to  assume  irregular  positions.  As  a  result  of  this,  not 
only  the  soft  parts  of  the  mouth,  but  even  the  bony  framework  of 


Fig.  1. — The  head  of  infancy.     (Bell.) 


the  lower  face  is  permanently  changed  A  relative  over-development 
of  the  upper  jaw  gives  an  expression  similar  to  that  of  an  imbecile. 
On  the  other  hand,  an  over-development  of  the  lower  jaw  forward 
produces  the  prognathous  condition  which  makes  the  face  assume  a 
canine  look.  These  alterations  only  are  mentioned  here,  so  as  to 
call  attention  to  the  necessity  of  early  regulation  of  dental  irregu- 
larities, which  produce  all  degrees  of  change  in  the  physiognomy. 

The  face  of  the  infant  is  small  in  comparison  with  the  rest  of  the 
head;  but  the  development  of  the  accessory  sinuses  of  the  nose  and 
of  the  jaws  in  the  adult  alter  the  relation.  The  cranium  of  a  baby  is 
five  or  six  times  as  large  as  tbgs^face.  The  cranium  and  face  of  the 
adult  woman  retain  to  a  certain  extent  an  appearance  of  immaturity 
and  show  less  marked  prominences  and  ridges,  than  in  the  man.     It 


A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE 


17 


is  proportionally  smaller  than  the  male  face  and  has  narrower  and 
less  prominent  jaws. 

The  development,  as  the  infant  grows,  of  the  superciliary  ridges 
and  frontal  sinuses  in  the  lower  part  of  the  frontal  bone  makes  the 
frontal  eminences  less  conspicuous;  and  therefore  the  forehead  as- 
sumes a  more  receding  character.  The  face  at  birth,  in  addition  to 
being  relatively  small,  is  short  in  comparison  to  its  breath,  and  lacks 
the  prominence  of  the  adult  face.  The  region  about  the  eyes  is  better 
developed  than  the  middle  and  lower  portions.  The  floor  of  the  orbits 
at  their  outer  sides  is  situated  not  much  above  the  bottom  of  the 


Fig.   la. — The  head  of  the  aged.      Senile  changes  in  the  mandible.      (Bell.) 


nasal  chambers;  the  jaws  show  little  alveolar  process,  because  the 
teeth  have  not  been  erupted;  the  body  of  the  lower  jaw  is  not  devel- 
oped and  its  rami  are  very  oblique;  the  chin  is  small,  and  the  temporal 
ridge  and  fossa  and  the  zygomatic  arch  are  inconspicuous. 

Bell  believed  that  the  fulness,  roundness  and  chubbiness  of  the 
infant's  face  are  due  to  the  circumstance  that  the  soft  parts  are  ex- 
pected to  meet  the  requirements  to  which  they  are  to  be  subjected  by 
the  increased  size  of  the  bony  framework  of  the  face  in  later  years. 
As  the  child  grows,  the  bones  of  the  face,  especially  the  jaws,  increase 
at  a  proportionately  more  rapid  rate  than  those  of  the  cranium;  and 
the  face  is  less  round  than  in  the  baby.     The  superciliary  ridges, 


18 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


moreover,  begin  to  appear  as  the  frontal  sinuses  are  developed  and 
finally  become  a  prominent  characteristic  of  the  face  of  the  adult. 

At  the  time  of  the  first  dentition  the  lower  part  of  the  face  in- 
creases in  relative  size,  the  chin  becomes  more  prominent,  the  jaws 
become  deeper  and  lengthen,  the  rami  of  the  lower  jaw  become  more 
vertical,  and  the  zygomatic  arch  begins  to  give  its  characteristic  ap- 
pearance to  the  side  of  the  face.  The  later  dental  changes  and  the 
adolescent  growth  of  the  accessory  sinuses  of  the  nose  induce  still  more 
marked  alterations  in  the  facial  outlines,  especially  if  the  ventilation 
of  the  nose  and  nasopharynx  is  not  obstructed.  The  angle  of  the 
inferior  maxilla  recedes  and  becomes  prominent,  and  the  square  chin 


Fig.  2. — ^Facial  angle  of  Caucasian  skull, 
ab  and  dc  are  lines  enclosing  angle.  1.  Audi- 
tory meatus;  2,  nasal  spine;  3,  frontal  emi- 
nence.    (Camper.) 


Fig.  3. — Facial  angle  of  negro,     ab  and  ac 
enclose  angle  at  2.     (Camper.) 


and  well  developed  jaws  succeed  the  rounded  and  plump  face  of  the 
child.  In  old  age  the  teeth  are  lost,  the  alveolar  processes  of  the  jaws 
disappear,  the  angle  between  the  axes  of  the  body  and  ramus  of  the 
lower  jaw  increases,  and  the  face  becomes  correspondingly  shorter, 
resembling  the  face  of  infancy.  The  body  of  the  lower  jaw  has  a 
larger  arch  than  its  alveolar  border.  Hence,  as  the  alveolus  is  ab- 
sorbed the  jaw  is  drawn  upward,  bringing  the  chin,  now  markedly 
prominent,  nearer  to  the  nose,  the  lips  fall  in  and  the  mouth  becomes 
too  small  for  the  tongue.  These  characteristics  of  old  age  may  be 
developed  in  those  persons  who  are  not  extremely  old  when  the 
teeth  are  lost  prematurely  from  any  cause. 

The  human  face  taken  as  a  whole  has  varying  characteristics  in 
the  different  races  of  man  and  in  different  individuals  of  the   same 
It  may  be  broad  or  narrow,  long  or  short,  oval  or  round,  large 


race. 


or  small,   receding  or  prominent.     Some  persons  have  faces  which 


A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE 


19 


are  peculiarly  concave  or  dish-shaped  in  the  center,  though  a  promi- 
nent central  contour  is  more  common. 

The  degree  to  which  the  lower  part  of  the  face  is  thrust  forward 
has  much  influence  upon  the  whole  appearance  of  the  individual. 
A  protruding  face  is  called  prognathous,  the  non-protruding  face 
orthognathous,  and  a  broad  face  eurygnathous.  The  Caucasian  face 
is  orthognathous  and  often  prominent  mesially  and  centrally,  while 
the  African  and  Mongolian  races  are  prognathous.  The  last  are 
characterized  by  faces  which  are  broad  and  centrally  depressed  as 
well  as  prognathous. 


Fig.  4. — Face  of  African  negro.      {Bell.) 


Fig.   .5. — Head  of  antique  statue.      (Bell.) 


The  relative  size  of  the  face  to  the  cranium  or  rest  of  the  head  is 
indicated  by  the  facial  angle.  This  angle  is  ascertained  by  drawing 
a  horizontal  line  from  the  anterior  nasal  spine  to  the  auditory  meatus 
and  dropping  a  second  line  from  the  glabella,  the  smooth  portion  of 
the  frontal  bone  above  the  fronto-nasal  suture,  to  the  alveolar  process 
of  the  upper  j  aw. 

The  angle  between  these  lines  at  the  anterior  nasal  spine  is  the 
facial  angle  of  Camper.  In  the  Caucasian  this  angle  averages  about 
80°,  in  the  Mongolian  about  75°,  in  the  African  about  65°.  In  the 
lower  animals  of  man's  class  the  facial  angle  is  much  less;  and  the 
proportionate  size  of  the  face  is  so  great  compared  with  the  decreasing 
brain  cavity  that  the  face  is  almost  entireh^  in  advance  of  the  cranium. 
The  facial  angle  of  the  gorilla  is  about  31°.     The  facial  angle  of  man 


20 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


is  never  a  right  angle,  but  the  ancient  sculptors  made  it  so  in  their 
representation  of  mythological  beings,  to  whom  they  desired  to  give 
the  appearance  of  unusual  intellectual  development. 

Beneath  the  skin  of  the  face  lie  the  sheets  of  muscular  tissue, 
which  give  expression  to  the  countenance.  They  have  one  end  at- 
tached to  the  bones  of  the  face,  which  with 
the  exception  of  the  lower  jaw  are  stationary, 
and  the  other  end  inserted  into  the  under 
surface  of  the  skin.  Contraction  of  such 
muscular  fibers  causes  the  more  movable 
end  and  its  attached  skin  to  approach  the 
fixed  end.  This  shortening  of  the  fibers 
rucks  the  skin  up  into  folds,  with  intervening 
wrinkles,  which  are  at  right  angles  to  the 
direction  of  the  muscular  pull.  In  subjects 
whose  skin  is  thin  and  flexible  the  muscular  contraction  causes 
many  and  delicate  wrinkles  to  appear.  When  the  skin  is  thick 
and  stiff  by  nature,  or  as  the  result  of  disease,  such  as  myxedema, 
a  slight  action  of  the  muscles  of  expression  will  produce  no  visible 
wrinkling  of  the   surface.     The   more   active   muscular   contraction 


Fig.  6. — Facial  angle  of 
monkey,  shown  by  lines  ab  and 
dc.      (Camper.) 


..i> 


Fig.  7. — Facial  angle  of  Apollo.     Angle  shown  between  lines  ab  and  3c  crossing  near  2.     {Camper.) 


required  in  this  case  to  give  evidence  of  its  occurrence  will  cause  few 
and  thick  wrinkles.  The  delicate  shades,  variety  and  beauty  of 
facial  expression  are  absent  under  such  circumstances. 

The  muscles  of  expression  are  difficult  of  dissection,  because  they 
are  small,  of  loose  texture,  and  somewhat  pale  in  color,  and  from  the 
fact  that  the  removal  of  the  skin  dissects  away  the  tissue  into  which 
the  muscle  is  inserted. 


A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE 


21 


There  are  two  muscular  landmarks  on  the  front  of  the  face — about 
the  eyes  and  around  the  mouth.  Encircling  each  orbit  is  the  orbicular 
muscle  of  the  eyelids.  Each  of  these  arises  at  the  inner  side  from  the 
nasal  process  of  the  upper  jaw,  the  tendon  of  the  eye-lids,  and  the 
frontal  bone.  It  is  a  sphincter  muscle  and  encircles  the  orbit,  its 
fibers  being  inserted  on  the  outer  side  of  the  orbit  into  the  external 
tarsal  ligament  and  the  malar  bone.  The  orbicular  muscle  of  the 
eyelids  by  its  central  fibei's  closes  the  eyelids.  The  elliptical  fibers 
running  around  its  outer  margin  draw  the  brow  down,  and  the  lower 


Fig.  8. 


Fig.  9. 


Fig.  8. — Diagram  sho\\ing  Knes  in  forehead  due  to  contraction  of  frontal  part  of  occipito-frontal 

muscle.     These  furrows  give  expression  of  attention  to  the  face.      (Duval.) 
Fig.  9. — The  emotion  of  attention  and  astonishment  expressed  by  contraction  of  frontal  muscles. 

(Duval.) 


eyelid  up,  thus  wrinkling  its  edges  and  forcibly  closing  the  eyes. 
It  produces  at  the  outer  side  of  the  eye  the  radiating  wrinkles  which 
in  old  age,  when  the  skin  is  inelastic  and  the  underlying  fat  has  been 
absorbed,  become  very  conspicuous  and  are  called  "crow's-feet." 

A  similar  orbicular  or  sphincter  muscle,  called  the  orbicular  of  the 
mouth,  surrounds  that  opening  and  constitutes  the  muscular  mass  of 
the  lips.  It  differs  from  the  circular  muscle  of  the  eyelids  in  having 
its  fixed  attachments  in  the  middle  line  above  and  below,  instead  of 
at  its  outer  and  inner  ends.  Its  attachment  to  the  upper  jaw  below 
the  nose  and  to  the  lower  jaw  in  the  middle  line  permit  the  lips  to  be 
puckered  in  whistling.  There  are  two  naso-labial  muscular  slips, 
which  connect  the  upper  lip  to  the  septum  of  the  nose.  The}'  have  an 
interval  between  them  which  makes  the  well-known  depression  in  the 


22 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


skin  just  below  the  columella.  These  are  accessory  fibers  of  the 
orbicular  muscle.  Many  of  the  muscles  of  expression  are  inserted 
into  or  blend  with  the  fibers  of  the  orbicular  of  the  mouth,  and  by 
acting  upon  it  make  great  changes  in  the  expression  of  the  face. 

The  so-called  occipito-frontal  muscle  is  really  two  muscles: — a 
posterior  attached  to  one  end  of  the  fascia  covering  the  top  of  the 
cranium,  and  an  anterior  or  frontal  portion,  inserted  in  a  similar 
manner  into  the  front  part  of  that  fascia.     The  frontal  portion  arises 


Translferse 
facial  art. 


TEMPORAL 


iMSsrj*. ^jTron  taZ  art. 

PrffAM/DALIS  NA.Sf 

/Angular  art^ 
Lateral 
I  nasf  art. 


coMPnsssoR 

/VAfi/S- 

Tjvasaln. 


Auricula 
temporal .  _ . 
/Superficial ,       jr^-^f, 

temporalart  W\/ 
Tempf  branches  y/l 
Cervico- facial  /  V'\ 
div-ision  ,  '^  Us 
Su.73ramaxillari/j^ 
hran-c/i    -^■ 


Submental 
■<sss^\        _  art. 
S  Jnfriadialart, 


2£.Coh.n,adnaturcc7n  dleZ. 


Fig.  10. — Dissection  of  muscles  of  face.     (PFeiss.) 


from  the  nasal  bones  and  the  external  angular  processes  of  the  frontal 
bone;  it  has  also  an  origin  from,  or  attachment  to,  the  fibers  of  the 
orbicular  of  the  eyelid  and  the  corrugator  of  the  eyebrow.  Its 
fibers  run  upward  to  be  inserted  into  the  aponeurosis  covering  the 
cranium.  The  frontal  muscle  raises  the  eyebrows  and  the  integu- 
ment at  the  root  of  the  nose,  bringing  at  the  same  time  the  scalp 
downward  so  as  to  cause  transverse  wrinkles  in  the  forehead.     The 


A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE 


23 


typical  furrow  or  line  produced  by  this  muscle  is  concave  upward  in 
the  middle  line  and  convex  upward  at  its  outer  extremities. 

Sometimes,  however,  this  wrinkle  may  be  a  straight  line;  at  other 
times  the  central  or  lateral  portion  is  poorlj^  marked  or  absent.  Occa- 
sionally when  the  central  portion  is  absent,  the  lateral  curves  meet  or 
cross  each  other.     This  muscle  has  been  called  the  muscle  of  attention. 

The  corrugator  supercilii,  or  wrinkler  of  the  eyebrow,  has  its  origin 
at  the  root  of  the  nose  and  is  inserted  into  the  skin  under  the  eyebrow. 
It  pulls  the  head  of  the  eyebrow  downward  and  forward,  making  an 
angle  in  the  brow  near  its  inner  end.  It  causes  a  frowning  expression, 
which  is  also  a  factor  in  the  expression  of  pain. 


Fig.  11. — Emotion  of  attention 
combined  with  astonishment  por- 
trayed on  the  stage  by  action  of 
the  frontal  muscles,  and  by  asso- 
ciated gestures. 


Fig.  12. — Diagram  representing  action 
of  corrugator  of  the  eyebrow  to  express 
pain  or  sorrow.      (.Duval.) 


The  greater  zygomatic  muscle  arises  from  the  cheek  bone  and  is 
inserted  into  the  skin  and  orbicularis  oris  at  the  angle  of  the  lips. 
The  lesser  zygomatic  with  a  similar  origin  is  seldom  present.  The 
elevator  of  the  upper  lip  arises  from  the  nasal  process  of  the  upper 
jaw  and  the  lower  margin  of  the  orbit  and  is  inserted  into  the 
upper  lip  and  adjacent  portion  of  the  wing  of  the  nose.  It  is 
often  divided  into  two  parts.  The  inner  is  called  the  elevator  of 
the  upper  lip  and  wing  of  the  nose,  the  outer,  the  proper  elevator 
of  the  upper  lip.  Another  small  muscle  arises  from  the  canine 
fossa  below  the  eye  and  is  inserted  into  the  lips  near  the  angle  of  the 
mouth.     It  is  the  elevator  of  the  angle  of  the  mouth. 

Arising  from  the  lower  jaw  not  far  from  the  chin  are  the  depressor 
of  the  angle  of  the  mouth,  the  depressor  of  the  lower  lip,  and  the 
elevator  of  the  lower  lip. 

The  orbicularis  oris,  when  the  inner  fibers  act,  draws  the  lips  close 
against  the  teeth  producing  the  so-called  "biting  of  the  lips,"  seen  in 


24 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


anger  or  menace.  When  the  outer  fibers  act,  it  pouts  the  lips  out 
as  in  whistling.  When  the  muscle  is  relaxed,  the  lips  turn  out  in  a 
flaccid  condition,  giving  the  face  a  lack  of  expression,  which  is  well 
marked  in  some  types  of  insanity. 

The  muscles  of  the  face  are  in  pairs.  The  frontal  and  orbicular  of 
the  mouth,  though  each  are  called  by  one  name,  are  really  composed 
of  two  lateral  muscles,  usually  acting  as  one. 

The  action  of  the  frontal  muscle,  as  previously  stated,  is  to  raise 
the  eyebrows  and  make  transverse  wrinkles  in  the  skin  of  the  forehead. 
It  has  been  called  the  muscle  of  attention.  When  it  acts  excessively, 
it  produces  the  appearance  of  astonishment. 


Fig.  13. — Emotion  of  grief  portrayed  on 
the  stage  by  action  of  the  corrugator  of  the 
eyebrow. 


Fig.  14. — Marked  naso-labial  line  in  the  aged- 


The  two  corrugator  supercilii  muscles  pull  the  eyebrows  inward 
and  downward  at  their  nasal  ends,  making  vertical  wrinkles  between 
the  eyebrows  above  the  root  of  the  nose.  This  gives  an  angularity 
to  the  inner  part  of  the  eyebrow  and  expresses,  by  a  frowning  cast  of 
countenance,  mental  and  physical  suffering. 

The  greater  zygomatic  muscle  draws  the  angle  of  the  mouth  up- 
ward and  outward  and  gives  the  expression  of  laughter  or  joy,  and 
causes  wrinkles  under  the  eyes.  The  little  band  of  muscle  arising 
from  the  fascia  over  the  masseter,  which  is  inserted  into  the  corner  of 
the  mouth  and  called  the  risorius,  is  not  as  its  name  would  indicate, 
the  laughing  muscle,  but  produces  a  grin  or  smile.  The  zygomatic 
is  the  true  muscle  of  laughter;  and,  by  pushing  up  the  muscular  mass 


A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE  25 

of  the  cheek,  causes  the  so-called  twinkling  of  the  eye  which  is  due 
to  the  wrinkles  under  the  eye  and  not  to  any  change  in  the  eye  itself. 

A  well-marked  furrow  in  the  face  is  the  naso-labial  line  which  ex- 
tends downward  and  outward  from  the  wing  of  the  nose  to  a  point 
external  to  the  angle  of  the  mouth.  It  is  seen  in  all  faces,  but  is  more 
marked  in  the  aged. 

The  naso-labial  line  changes  its  shape  with  varying  emotions. 
It  is  an  important  furrow  to  the  surgeon,  since  incisions  made  along 
its  groove  show  little  scar.  Incisions  across  it  should  be  avoided 
for  cosmetic  reasons.  In  laughter  the  naso-labial  line  assumes  a 
double  curve  like  the  old  italic  "  S" ;  in  pain  it  is  straight;  in  grief, 
convex  outward;  in  contempt  it  is  drawn  in  at  the  lower  end  and 
extended  around  the  angle  of  the  mouth. 


Fig.  15. — Diagram  representing  the  Fig.  16. — Child  about  to  cry.     Lower  lip 

change   in    the   naso-labial   furrow    in  is  thrust  outward  by  action  of  elevator  of 

contempt   by   action   of  the  depressor  lower  lip. 
of  the  angle  of  the  mouth.     (Duval.) 

The  elevator  of  the  angle  of  the  mouth  assists  the  zj^gomatic  in 
indicating  joy.  The  elevator  of  the  upper  lip  and  the  elevator  of 
the  upper  lip  and  wing  of  the  nose  raise  the  middle  portion  of  the 
mouth,  give  the  curve  of  grief  to  the  naso-labial  line  and  produce 
an  expression  of  sadness.  The  corners  of  the  mouth  are  generally 
at  the  same  time  drawn  a  little  downward  by  the  depressors  of  the 
corner  of  the  mouth  and  the  platysma  muscles.  The  elevator  of  the 
upper  lip  and  wing  of  the  nose  acts  upon  the  nostril  to  indicate  disgust. 

The  action  of  the  depressor  of  the  lower  lip  is  to  thrust  the  lip 
a  little  outward  at  the  same  time  that  it  is  drawn  downward.  This 
gives  the  expression  of  scorn.  The  elevator  of  the  lower  lip  wrinkles 
the  skin  of  the  chin  and  at  the  same  time  elevates  the  lip  and  thrusts 


26 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


it  forward.  It  expresses  doubt  or  disdain.  The  tremulous  action  of 
this  muscle  is  often  noticed  in  children  just  before  they  cry.  The 
corners  of  the  mouth  are  pulled  downward  by  the  depressors  of 
the  angle  of  the  mouth  and  impart  the  appearance  of  sadness  to  the 
lower  portion  of  the  face.  They  are  aided  by  the  elevation  of  the  up- 
per lip  which  makes  the  downward  movement  of  the  angles  of  the 
mouth  more  conspicuous. 

The  orbicular  muscle  of  the  eyelids  consists  of  two  portions;  one 
which  covers  the  eyelids  close  to  their  edges  and  produces  the  con- 
tinuous involuntary  winking.     The  outer  portion  of  the  muscle  en- 


FiG.  17. — Crude  diagrams  showing  changes  in  expression  by  alterations  of  naso-labial  furrows  and 
of  shape  of  line  between  the  lips. 


circles  the  margin  of  the  orbit.  When  the  whole  of  the  muscle  is  in 
action  the  eyelids  are  tightly  closed.  This  occurs  during  coughing, 
vomiting,  or  other  straining  efforts  which  would  tend  to  force  the 
eyeball  forward  by  the  venous  congestion  in  the  orbit.  The  upper 
portion  of  this  muscle  draws  the  eyebrow  downward  in  opposition  to 
the  action  of  the  frontal  muscle  and  thus  gives  the  face  an  expres- 
sion of  reflection  or  meditation.  A  few  of  the  fibers  of  this  muscle 
which  are  beneath  the  lower  eyelid  draw  that  lid  downward.  This 
action  makes  the  individual  have  the  appearance  of  benevolence, 
frankness  or  honesty. 

The  little  pyramidal  muscle  of  the  nose  arising  from  the   nasal 
bone  and  running  upward,  draws  down  the  inner  end  of  the  eyebrow  in 


A  SURVEY  OF  THE  ANATOMY  OF  THE  FACE  27 

the  expression  of  menace.  The  triangular  muscle  of  the  nose  running 
across  its  bridge,  wrinkles  the  skin  on  the  side  of  the  nose  in  a  longitud- 
inal direction.     It  is  said  to  indicate  the  emotion  of  lewdness. 

In  true  emotions  the  muscles  of  the  various  portions  of  the  face 
act  in  consonance  involuntarily,  and  produce  expressions  which 
seem  to  us  natural.  One  can,  however,  by  a  distinct  voluntary 
effort  bring  disassociated  muscles  into  action  and  thereby  produce 
a  grimace. 

It  is  interesting  to  observe  how  the  anatomical  situation  and 
nervous  supply  of  muscles  indicate  what  emotions  can  occur  together. 
This  anatomical  basis  of  expression,  as  it  may  be  called,  corresponds 
exactly  with  the  psychical  relations  of  the  phenomena.  It  is  im- 
possible for  one  to  give  attention  to  external  objects  and  be  at  the 
same  time  in  a  state  of  meditation.  Such  a  mental  contradiction  is 
anatomically  shown  in  the  fact  that  the  frontal  muscle  cannot  pull 
the  eyebrows  upward  to  indicate  attention  while  the  orbicular  of 
the  eyelids  is  pulling  it  down  to  indicate  meditation.  The  muscles 
which  elevate  and  draw  outward  the  corners  of  the  mouth  in  mirth 
cannot  contract  at  the  same  time  as  those  which  pull  the  corners  of 
the  mouth  downward  in  grief.  This  anatomical  fact  corresponds  with 
the  impossibility  of  mirth  and  grief  being  felt  by  the  individual 
at  the  same  time.  There  is,  however,  a  close  connection  between  the 
emotions  of  mirth  and  grief.  Everyone  knows  the  ease  with  which 
a  hysterical  woman's  face  oscillates  between  laughter  and  weeping. 
A  similar  uncertainty  is  shown  in  the  views  of  authors  as  to  the 
function  of  the  smaller  zygomatic  muscle,  which  when  present  lies 
between  the  greater  zygomatic — the  muscle  of  laughter — and  the  ele- 
vator of  the  upper  lip — a  muscle  of  sorrow.  This  shows  the  close 
anatomical  relationship  of  the  muscles  indicating  these  mental  states, 
which  are  really  not  widely  separated. 

The  surgery  of  the  face  must  not  alter  unnecessarily  the  rela- 
tions of  these  muscles  of  expression.  This  is  particularly  important 
in  dealing  with  the  mouth.  Many  do  not  appreciate  the  importance 
of  the  lower  part  of  the  face  in  expression.  The  muscles  about  the 
mouth  are  much  more  expressive  than  those  about  the  eyes.  This  is 
well  shown  in  these  crude  diagrams  of  the  face  in  which  the  line  of 
the  mouth  is  the  only  thing  changed.  One  figure  at  once  suggests 
mirth,  while  the  other  is  clearly  indicative  of  grief. 

The  size  and  shape  of  the  eyebrows  vary  very  much  in  different 
individuals.  Occasionally  they  meet  in  the  middle  line  above  the 
nose.  The  chief  surgical  point  in  regard  to  them  is  that  incision 
made  through  them  should  not  displace  the  skin  so  that  the  hair  will 


28  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

grow  unevenly  and  make  conspicuous  deformity.  Flaps  from  the 
head  or  grafts  from  the  pubes  with  hairs  in  them,  may  be  transplanted 
to  make  eyebrows.  Horizontal  incisions  made  along  the  superciliary 
ridge  among  the  hairs  cause  very  little  displacement,  and  the  scar  is 
hidden  by  the  hair.  Oblique  or  vertical  cuts  here  are  likely  to  leave 
uncomely  distortion  of  the  eyebrow. 

When  flaps  are  made  from  the  forehead  near  the  line  of  the  scalp 
or  close  to  the  eyebrows,  care  should  be  taken  to  avoid  including 
any  hair-bearing  portion  of  the  skin  in  the  flap,  unless  the  hairy 
portion  can  be  utilized  for  eyelashes,  eyebrows,  mustache  or  beard. 
When  the  exigencies  of  the  case  require  such  flaps  to  be  used,  the 
hair  may  be  destroyed  after  the  flap  has  taken  root  in  its  new  position 
by  electro  puncture  of  the  hair  follicles  or  by  the  a;-rays.  At  times 
incisions  may  be  satisfactorily  made  across  the  scalp  within  the  region 
of  hair  and  the  scalp  pulled  down  to  give  access  to  the  bones  of  the 
face.  The  scar  is  then  covered  by  the  hair.  I  have  satisfactorily 
used  a  flap  from  the  hairy  scalp  for  constructing  a  portion  of  the  cheek 
in  a  man.  This  was  unobjectionable,  because  the  flap  was  used  to 
fill  an  opening  in  the  region  of  the  beard.  The  hair  growing  on  the 
flap  caused  no  special  disfigurement.  The  disposition  of  the  tissues, 
in  plastic  surgery  of  the  upper  lip,  must  often  bear  relation  to  the 
growth  of  the  mustache. 


CHAPTER  III. 

CHARACTERISTICS  OF  SURGERY  IN  THE  FACE. 

The  cutaneous  covering  of  the  face  is  thin,  elastic  and  very  vas- 
cular. It  does  not  slide  very  freely  over  the  deeper  tissues,  because 
the  many  muscles  of  the  face  are  inserted  into  its  lower  surface  for 
the  purpose  of  causing  wrinkles  and  giving  expression  to  emotions. 
Its  vascularity  and  elasticity  render  it  particularly  suitable  for  plastic 
procedures.  If  loosened  from  its  deep  attachments  with  the  knife, 
it  can  be  stretched  into  new  positions,  without  much  probability 
of  sloughing  occurring  from  limitation  of  blood  supply.     The  tissues 


Fig.  18. — Diagram  showing  where  incisions 
may  be  made,  leaving  inconspicuous  scars. 
(Full  face.) 


Fig.  19. — Diagram  showing  where  incisions 
may  be  made,  leaving  inconspicuous  sears. 
(Profile.) 


of  the  face  are  so  mobile  and  susceptible  of  stretching  that  a  dis- 
tinguished English  surgeon  has  said  that  he  could  construct  a  mouth 
out  of  either  the  upper  or  lower  lip  alone. 

It  is  important  to  make  incisions,  when  operating  on  the  face, 
in  such  manner  as  will  result  in  inconspicuous  scarring.  This  is 
to  be  done  by  following  the  curved  furrows  in  the  skin  produced  by 
the  action  of  the  muscles,  and  by  placing  the  scar  in  the  places  usually 
obscured  by  shadows  or  hair.  When  this  cannot  be  done  the  cut 
should  be  made  parallel  to  the  facial  lines  of  the  region  rather  than 

29 


30  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

across  them.  A  slightly  curved  line  makes  a  less  conspicuous  scar 
than  a  straight  or  abruptly  curved  one.  Under  the  eyebrow,  beneath 
the  lower  edge  of  the  jaw,  behind  the  ear,  and  around  the  wing  of  the 
nose  are  regions  usually  in  shadow.  The  crow's-feet  at  the  external 
angles  of  the  eye,  the  curved  wrinkles  in  the  forehead,  and  the  naso- 
labial furrows  are  indications  to  the  thoughtful  operator  of  the  situ- 
ation and  direction  most  appropriate  for  operative  wounds.  In- 
cisions made  in  these  furrows  or  parallel  to  them  leave  little  notice- 
able scarring.  Sometimes  the  incision  may  be  made  through  the 
hair  of  the  scalp  or  the  beard,  and  the  skin  may  then  be  drawn  aside, 
so  as  to  expose  the  deep  structures  at  a  considerable  distance  from 
the  cut. 

Accurate  apposition  of  the  edges  of  a  wound  is  best  obtained  in  inci- 
sions dividing  the  skin  somewhat  obliquely  to  the  plane  of  its  surface. 
The  bevelled  edges  of  skin  thus  made  fit  accurately  together  and 
cause  very  little  scarring.  Scars  received  in  childhood  increase  pro- 
portionately with  the  growth  of  the  patient.  This  circumstance  may 
cause  cicatrices  which  seem  insignificant  in  childhood  to  become 
marked  defects  in  adult  life,  though  the  original  induration  and 
discoloration  about  the  scar  have  long  disappeared. 

Bleeding  is  free  in  operations  upon  the  face,  but  soon  ceases 
if  pressure  is  made  with  hemostatic  forceps  or  sponges.  Operating 
with  the  patient  semi-erect  lessens  the  bleeding.  Torsion  or  liga- 
tion with  cat-gut  may  be  occasionally  required.  Acu-pressure  or 
tempory  subcutaneous  ligation  of  the  facial  arteries,  where  they 
cross  the  lower  jaw  bone,  will  diminish  the  blood  supply  during  the 
time  of  operation.  Digital  compression  may  be  used  on  the  external 
carotid  arteries  just  below  the  ear  to  make  the  temporary  anemia  more 
complete.  To  be  of  service  the  arteries  of  both  sides  of  the  face  should 
be  controlled.  In  very  serious  operations  upon  the  face  both  common 
carotids  may  be  temporarily  clamped. 

Septic  inflammations  after  operations  upon  the  face  may  usually 
be  avoided  by  thoroughly  sterilizing  the  parts  prior  to  operation  and 
before  applying  the  sutures,  and  subsequently  keeping  the  wound 
perfectly  dry  or  removing  all  secretion  by  frequent  antiseptic  irrigation. 

Valves  are  not  common  in  the  veins  of  the  face.  This  circum- 
stance and  the  free  communication  of  the  facial  veins  with  the  internal 
jugular  veins  and  cavernous  sinuses  are  given  as  reasons  for  the  rapid 
spread  of  septic  inflammations  when  they  occur  in  the  tissues  of  the 
face. 

The  bony  framework  of  the  face  has  a  good  blood  supply  and  is 
not  likely  to  become  necrotic  unless  septic  inflammation  of  a  high 


CHARACTERISTICS  OF  SURGERY  IN  THE  FACE  31 

grade  is  present.  The  bones  are  comparatively  soft  and  do  not  split 
easily  when  broken.  Union  after  fracture  or  incision  occurs  with 
rapidity.  There  seems  to  be  a  certain  amount  of  elasticity  in  the 
bones  of  the  face  which  enables  them  to  regain  the  normal  contour, 
if  the  displacing  pressure  has  not  been  great. 

The  soft  tissues  are  similarly  well  supplied  with  blood  and  will 
often  recover  from  severe  injury,  which  in  other  parts  of  the  body 
would  lead  to  local  gangrene.  The  maintenance  of  an  aseptic  condi- 
tion and  the  application  of  heat  to  the  damaged  structures  will  often 
result  in  saving  tissue  apparently  devitalized.  Frequent  irrigation, 
with  sterile  normal  salt  solution  or  weak  antiseptic  solutions,  of  the 
temperature  of  105°  F.  is  a  serviceable  means  of  obtaining  the  condi- 
tions mentioned.  Dry  heat  is  better  than  moist  heat  if  the  wound  is 
aseptic  and  gangrene  is  feared  from  anemia  alone.  Portions  of  the 
nose,  ear,  or  lip,  which  have  been  torn  or  cut  off,  may  be  re-adjusted 
and  sutured  in  their  normal  position  with  a  fair  prospect  of  union 
taking  place. 

Plastic  procedures  upon  the  face  may  involve  extensive  areas 
without  grave  danger  of  the  result  being  interfered  with  by  gangrene 
of  the  flaps.  Accidental  injuries  should  be  treated  on  this  basis  and 
no  sacrifice  of  doubtful  tissue  should  be  made,  until  the  impossibility 
of  its  preservation  has  been  established  by  the  actual  occurrence  of 
sloughing.  The  most  perfect  approximation  of  the  edges  of  cutaneous 
incisions  is  obtained  when  the  incision  has  been  made  obliquely  to  the 
plane  of  the  surface.  Such  bevelled  edges  are  brought  together  with 
great  accuracy  if  fine  needles  and  sutures  are  employed.  Accidental 
wounds  will  at  times  cause  less  scar,  if  the  edges  are  trimmed  obliquely 
in  opposite  directions  before  sutures  are  inserted. 

Fine  silk,  silkworm  gut,  or  Pagenstecher  linen  thread  is  the  best 
suturing  material  for  wounds  of  the  face,  as  ordinary  catgut  may  be 
absorbed  at  a  too  early  period  and  allow  separation  of  a  portion  of  the 
wound.  In  applying  the  sutures  a  line  for  the  scar  should  be  chosen, 
which  will  displace  by  contraction  the  eyelids,  ala  of  nose,  or  mouth  as 
little  as  possible.  It  should  be  at  a  right  angle  to  the  line  of  the 
tissue  which  the  surgeon  fears  may  be  displaced.  The  twisted  or 
pin  suture  is  always  undesirable  in  the  lips  or  face.  It  is  not  needed 
even  in  harelip  operations.  A  little  piece  of  serile  cotton  laid  over 
the  wound  is  a  very  nice  dressing.  I  sometimes  appl}^  no  dressing 
after  operations  upon  the  soft  parts  of  the  face,  allowing  the  bloody 
serum  and  lymph  oozing  between  the  sutures  from  the  edges  of  the 
aseptic  wound  to  dry.  If  it  is  deemed  desirable,  a  little  boric  acid  or 
acetanilid  may  be  dusted  along  the  edge  to  encourage  the  formation 


32  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

of  this  aseptic  scab.  These  methods  of  dressing  are  less  cumbersome 
and  therefore  more  agreeable  to  the  patient  than  great  bundles  of 
gauze  held  upon  the  face  by  means  of  bandages.  The  least  evidence 
of  suppuration  under  the  scab  must  be  an  indication  to  soak  the  crust 
with  an  antiseptic  lotion  and  remove  it.  If  this  is  not  done  promptly 
pus  will  burrow  and  render  rapid  union  impossible  and  scarring  likely. 

Drainage  is  seldom  needed  in  wounds  of  the  face  and  should  be 
avoided  whenever  possible,  as  it  tends  to  increase  the  disfigurement 
from  scarring.  The  sutures  should  usually  not  be  allowed  to  remain 
more  than  five  days.     Some  may  often  be  removed  earlier. 

In  external  wounds  involving  the  cavity  of  the  mouth  a  series  of 
sutures  introduced  from  within  the  mouth  to  hold  the  edges  of  the 
mucous  membrane  together  will  be  advantageous.  The  germs  con- 
tained in  the  mouth  are  then  less  likely  to  gain  access  to  the  surfaces 
of  the  wound  and  the  cutaneous  portion  is  more  likely  to  unite  by 
first  intention. 

When  operating  upon  the  exterior  of  the  cheek,  the  surgeon  should 
avoid  incising  the  mucous  membrane  whenever  possible.  Contamina- 
tion from  bacteria  within  the  mouth  is  thus  avoided.  Drainage 
when  necessary  should  be  connected  with  the  mouth,  thus  avoiding 
the  scarring  of  the  external  surface  by  drainage  threads  or  tubes. 

A  neat  method  of  approximation  which  causes  only  one  or  two 
needle  punctures  on  the  external  surface  is  by  a  subcuticular  or  intra- 
cutaneous continuous  suture.  Fine  linen  or  silkworm  gut  and  a  small 
straight  or  semicircular  needle  are  employed.  The  needle  is  thrust 
through  the  skin  near  one  end  of  the  wound  and  its  point  made  to 
emerge  within  the  wound  close  to  the  extremity.  By  this  maneuver  the 
thread  has  its  end  anchored  in  the  tissues.  The  needle  is  then  used 
to  draw  the  raw  surfaces  of  the  skin  together,  by  taking  hold  of  the 
faces  of  the  two  walls  of  the  wound  successively  but  never  being  al- 
lowed to  puncture  the  external  surface  of  the  integument.  When  the 
wound  has  been  thus  closed  along  its  entire  extent  the  thread  is  cut 
off  short  and  allowed  to  retract  within  the  tissues  or  the  needle  is 
thrust  through  the  skin  and  brought  out  upon  the  surface  at  a  little 
distance  from  the  extremity  of  the  wound.  The  thread  in  the  latter 
case  is  cut  off  so  as  to  leave  an  inch  or  so  protruding.  W^hen  the 
wound  has  healed,  traction  on  either  end  of  the  suture  will  pull  the 
entire  thread  from  its  position  within  the  layers  of  the  skin.  Catgut, 
if  used,  will  be  absorbed  and  is  not  withdrawn.  If  there  is  much 
tension  to  be  overcome  by  the  suture  it  may  be  necessary  to  make 
a  knot  on  the  thread  projecting  at  the  first  puncture,  and  to  anchor 
the  other  end  of  the  thread  as  in  the  ordinary  continued  suture.     This 


CHARACTERISTICS  OF  SURGERY  IX  THE  FACE  33 

manner  of  burying  the  sutures  is  unnecessary,  if  oblique  incisions  and 
small  needles  are  used  in  the  ordinary  way  with  the  maintenance 
of  a  perfectly  aseptic  wound. 

Incisions  in  the  middle  of  the  cheek  should  be  made  so  as  to  avoid 
wounding  the  duct  of  the  parotid  gland.  This  duct  is  beneath  the  deep 
fascia  and  runs  in  a  line  drawn  from  about  the  middle  of  the  lobe  of  the 
ear  to  a  point  midway  between  the  wing  of  the  nose  and  the  angle  of 
the  mouth.  When  the  duct  reaches  the  anterior  edge  of  the  masseter 
muscle,  in  its  course  forward  from  the  parotid  gland,  it  dips  inward 
toward  the  mouth,  perforating  the  buccinator  muscle  and  the  mucous 
membrane  in  an  oblique  direction.  It  enters  the  mouth  opposite 
the  second  molar  tooth  of  the  upper  jaw. 

AVhen  it  is  impossible  to  avoid  cutting  this  duct,  the  portion  be- 
tween the  incision  and  the  parotid  gland  should  be  separated  from 
the  surrounding  tissues  for  a  short  distance  and  carried  into  the  mouth 
through  a  new  opening  in  the  mucous  membrane  and  other  tissues  of 
the  cheek.  This  device,  if  successfully  accomplished,  carries  the 
saliva  into  the  mouth  and  prevents  the  formation  of  a  salivary  fistule 
on  the  outside  of  the  cheek.  Incisions  under  the  outer  angle  of  the 
supraorbital  arch  may  if  very  deep  injure  the  lachrymal  gland  and 
lead  to  lachrymal  fistule. 

The  branches  of  the  seventh  nerve  radiate  from  a  point  a  little 
below  the  external  ear.  The  muscles  of  expression  in  the  face  will 
be  paralyzed  if  these  nerve  branches  are  cut.  The  motor  paralysis, 
due  to  injury  of  the  branches  of  the  seventh  nerve,  renders  the  patient 
unable  to  close  his  eye,  permits  the  mouth  to  droop  on  the  injured 
side,  and  renders  the  face  on  that  side  expressionless.  Injuries  to 
these  nerves  are  therefore  very  unfortunate  occurrences.  Vertical 
incisions  in  front  of  the  ear  are  therefore  to  be  avoided.  The  branches 
of  the  fifth  cranial  nerve,  which  give  sensation  to  the  face,  make  their 
exit  from  the  supraorbital,  infraorbital,  and  mental  foramina.  Injury 
to  these  sensory  branches  is  not  a  matter  of  much  consequence;  as 
loss  of  sensation  so  produced  makes  no  difference  in  the  appearance 
of  the  face. 


CHAPTER  IV. 
THE   PRINCIPLES   OF   PLASTIC   SURGERY   OF  THE   FACE. 

Plastic  surgery  is  often  called  into  requisition  to  repair  deformities 
of  the  face,  the  result  of  injury  or  disease,  or  congenital  malformation. 
Displacement  of  tissue  by  stretching  or  sliding,  transferring  a  flap 
with  a  pedicle,  and  transplanting  shavings  or  grafts  of  skin  or  other 
tissue  are  often  useful  in  correcting  such  disfigurements. 

Sometimes  the  pediculated  flap  cut  for  repairing  a  gap  is  not 
sutured  into  the  place  intended  until  inflammatory  changes  have 
increased  its  vascularity  and  thickness.  It  is  less  liable  to  slough 
under  these  circumstances  than  when  subjected  to  the  stretching  nec- 
essary to  put  it  in  proper  position  just  after  it  has  been  cut  and  while 
it  is  somewhat  lowered  in  vitality.  It  may  be  allowed  to  lie  loosely 
upon  a  piece  of  rubber  tissue  or  oil  silk  inserted  between  its  lower  sur- 
face and  the  tissues  beneath.  It  will  thus  be  prevented  from  becoming 
adherent  to  the  subjacent  structures.  In  three  or  four  days  it  will 
have  an  unusual  blood  supply  coming  to  it  through  its  pedicle  as  the 
result  of  the  inflammatory  irritation  produced  by  the  injury  sustained 
when  it  was  cut. 

The  suffix  ''plasty"  is  often  added  to  the  name  of  the  organ  con- 
structed, to  indicate  the  character  of  the  operation.  Thus,  rhinoplasty 
indicates  that  the  nose  or  a  portion  of  that  organ  has  been  made; 
cheiloplasty  refers  to  the  formation  of  a  lip;  meloplasty,  the  construc- 
tion of  a  cheek;  blepharoplasty,  the  making  of  an  eyelid. 

Plastic  surgery  may  have  for  its  object  the  curtailing  of  abnor- 
mally large  organs  as  well  as  the  repair  of  destroyed  or  deformed  ones. 
Thus  the  reduction  of  a  large  nose,  lip,  or  ear  is  properly  a  procedure 
in  plastic  surgery.  Constructive  operations  usually  make  use  of  the 
skin  and  subcutaneous  cellular  tissue,  or  the  mucous  membrane. 
The  last  assumes  a  character  somewhat  like  that  of  the  skin  when 
placed  upon  the  external  surface.  Muscle,  tendon,  nerve,  periosteum 
and  bone  are  employed  in  some  reparative  operations. 

Plastic  operations  should  not  be  done  while  the  patient  is  in 
poor  health,  nor  when  septic  contamination  of  the  wound  is  partic- 
ularly likely  to  occur.  Asepsis  of  wounds  is  of  primary  importance. 
Deformities  due  to  syphilis  should  not  be  corrected  by  operation 

34 


PRINCIPLES  OF  PLASTIC  SURGERY  OF  THE  FACE  35 

until    the    syphilitic    process    has    been    stayed    by    active   specific 
treatment. 

It  often  requires  a  series  of  operations  to  obtain  the  best  cosmetic 
result.  The  major  portion  of  the  operation  may  frequently  be  clone 
at  first;  but  improvement  may  often  be  obtained  later,  because 
the  new  tissue  may  then  be  shaped  with  more  accuracy.  Time 
should  be  given,  between  two  such  operations,  to  permit  the  shrinking 
which  occurs  when  the  inflammatory  exudate  is  absorbed.  It  is  much 
better  to  have  too  much  tissue  than  too  little,  in  the  first  stage  of  the 
operation,  if  the  plastic  procedure  is  undertaken  to  restore  a  lost  part. 

Care  in  introducing  sutures  will  permit  the  surgeon  to  cause 
apposed  edges  to  protrude  a  little  or  to  be  depressed.  The  obli- 
quity with  which  the  suture  needle  is  carried  through  the  skin  deter- 
mines which  of  these  conditions  is  obtained.  The  selection  of  points 
for  putting  in  sutures  also  determines  where  the  tension  will  come. 
Sutures  crossing  the  wound  obliquely  enable  the  surgeon  to  distrib- 
ute tension  in  various  areas. 

Three  general  methods  of  operating  include  most,  if  not  all,  plastic 
operations.  The  first  is  by  stretching  or  sliding  tissue  and  may  be 
called  the  method  by  displacement.  One  of  the  forms  of  displace- 
ment is  simple  approximation  after  freshening  the  edges;  as  in  hare- 
lip operations  and  in  remedying  the  ugly  notches  found  in  the  lobe 
of  the  ear  after  an  ear-ring  has  been  torn  from  that  organ. 

A  second  form  of  displacement  is  sliding  the  skin  into  position 
after  transferring  the  tension  to  an  adjoining  locality.  This  means 
is  employed  in  lifting  up  the  lower  eyelid  b}^  a  "V  "-shape  incision 
in  cases  of  ectropion.  The  linear  incision  sometimes  made  to  permit 
the  skin  to  be  pulled  laterally  over  wounds  is  another  illustration 
of  this  second  form  of  displacement. 

In  the  method  which  may  be  called  interpolation,  the  tissue 
to  be  used  is  taken  from  an  adjacent  region,  from  a  limb  or  even  from 
another  person  or  animal.  Under  this  treatment  are  included  trans- 
ferring a  flap  with  a  pedicle,  transplanting  tissue  without  a  pedicle, 
and  grafting  a  piece  of  tissue  from  the  thigh  or  abdomen  into  the  hand 
and  subsequently  inserting  it  into  the  face  or  elsewhere,  by  using 
the  arm  and  hand  as  a  means  of  transportation.  The  flap  with  a  ped- 
icle, by  which  it  receives  its  blood  supply,  may  be  rotated  in  its 
own  plane  through  a  quarter  or  half  circle,  as  in  making  an  eyelid 
from  the  forehead.  It  may  be  twisted  on  its  side,  as  in  forming 
the  wing  or  lateral  portion  of  the  nose  from  the  upper  lip  or  fore- 
head. Sometimes  the  flap  is  turned  entirely  over  so  that  the  raw 
surface  is  uppermost. 


36  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

One  flap  may  be  superimposed  upon  another,  as  in  one  of  the  op- 
erations for  forming  a  nasal  bridge,  where  the  forehead  flap  is  turned 
downward  and  a  flap  from  the  cheek  on  each  side  of  the  nose  drawn 
over  it  and  sutured  in  the  middle  line.  A  flap  may  be  jumped  across 
a  bridge  of  skin,  its  end  being  used  to  fill  a  space  on  the  far  side  of 
the  bridge  of  healthy  skin.  The  pedicle  is  usually  divided  in  such 
cases  when  the  flap  has  become  attached  in  its  new  position. 

Transplantation  without  a  pedicle  was  seldom  serviceable,  except 
in  skin  grafting,  until  surgeons  obtained  a  knowledge  of  the  means  of 
preventing  suppuration  in  wounds.  It  was  used  with  considerable 
success,  however,  in  the  transplantation  of  minute  pieces  of  skin. 
Now,  however,  large  shavings  of  skin  are  constantly  and  successfully 
employed  to  cover  recent  wounds  and  granulating  surfaces.  Quite 
large  portions  of  the  entire  skin  may  be  successfully  transplanted, 
if  the  operation  is  done  aseptically  and  the  wound  kept  free  from 
antiseptic  or  other  irritants.  It  is  best  to  have  the  tissues  abso- 
lutely dry.  Wolfe  and  Krause  have  advocated  this  method.  Portions 
of  bone  and  nerve  as  well  as  skin  are  also  quite  frequently  transplanted. 
Tissues  taken  from  the  lower  animals  or  recently  amputated  limbs 
are  sometimes  used,  though  the  patient's  own  tissues  are  more  fre- 
quently utilized. 

Portions  of  ear  and  nose  which  have  been  cut  off  by  accident  may 
be  sutured  in  place  with  a  rea.sonable  hope  of  union  occurring.  To 
accomplish  this  the  parts  must  be  aseptic  when  applied,  and  must  be 
kept  so  for  a  number  of  days  until  union  is  established.  The  main- 
tenance of  heat  in  the  severed  part  is  important.  Hot  normal  salt 
solution  and  solutions  of  boric  acid  and  other  mild  non-irritating 
antiseptics  are  often  used  for  this  purpose.  There  is  no  reason  why 
a  nose  or  ear  may  not  be  reconstructed,  with  almost  certain  success, 
from  portions  of  these  organs  deliberately  cut  from  other  persons, 
if  the  latter  are  willing  to  undergo  the  mutilation. 

Retrenchment  removes  unnecessary  tissue  and  improves  the  ap- 
pearance of  the  part  by  cicatricial  contraction.  Examples  of  this 
method  in  plastic  surgery  are  the  removal  of  elliptical  or  semi-ellip- 
tical portions  of  tissue  in  drooping  of  the  upper  eyelid,  the  cutting 
away  of  triangular  or  wedge-shaped  pieces  of  skin  or  muscle  in  less- 
ening the  bulk  of  the  lower  lip  or  tip  of  the  nose,  and  excision  of 
angiomatous  tissue  from  under  the  skin  of  the  cheeks. 

Retrenchment  is  also  of  service  in  the  cosmetic  surgery  of  the 
face  by  altering  the  comparative  size  of  features.  A  flat  and  tense 
lip  after  a  harelip  operation  is  made  to  look  more  comely  by  cutting 
a  wedge-shape  piece  out  of  the  center  of  the  lower  lip.     This  retrench- 


PRINCIPLES  OF  PLASTIC  SURGERY  OF  THE  FACE  37 

ment  of  the  normal  lower  lip  makes  the  tight  upper  lip  much  less  notice- 
able. In  the  same  way,  removal  of  a  portion  of  the  upper  lip  will 
make  a  small  nose  seem  more  prominent. 

Successful  plastic  surgery  is  more  apt  to  be  obtained  when  the 
patient  is  in  good  general  health,  and  when  the  seat  of  operation  is 
free  from  septic  inflammation.  Healthy  integument  should  always  be 
used  for  the  formation  of  flaps,  if  it  is  possible  to  obtain  it.  Cica- 
tricial tissue  has  less  blood  supply  and  consequently  diminished 
vitality;  it  is  apt  to  undergo  anemic  gangrene  when  dissected  from 
the  neighboring  tissues,  even  if  the  pedicle  is  a  broad  one.  Plas- 
tic operations  by  the  methods  of  approximation  and  sliding  interfere 
less  with  the  vascular  supply  than  do  transferring  or  transplanting 
flaps.  Therefore,  cicatricial  tissue  may  be  employed  more  freely 
in  the  former  than  in  the  latter  methods. 

Pedunculated  flaps  should  contain  a  good  deal  of  subcutaneous  tis- 
sue in  addition  to  skin;  such  flaps  contract  less  and  are  more  vascu- 
lar. They  should  have  a  wide  pedicle  and  should  be  about  one-third 
larger  in  area  than  the  space  to  be  covered.  Free  flaps,  or  grafts,  should 
have  the  subcutaneous  fascia  all  removed.  They  should  be  perhaps  a 
little  larger  than  pedunculated  flaps.  The  parts  to  be  repaired 
should  be  freshened  before  the  flap  is  cut,  because  the  tissue  that 
is  to  be  transferred  or  transplanted  may  then  be  promptly  put  into 
its  new  position,  before  it  loses  its  normal  heat.  Some  surgeons 
make  a  diagram  of  paper  before  beginning  a  plastic  operation,  and 
then  mark  a  similar  outline  with  ink  upon  the  skin.  This  is  as  a 
rule  unnecessary. 

The  long  axis  of  a  pedicle  should,  if  possible,  correspond  with 
the  direction  of  the  arterial  supply.  This  is  less  necessary  in  opera- 
tions upon  the  face  than  elsewhere  because  its  blood  supply  is  very 
abundant.  The  caliber  of  the  vessels  in  the  pedicle  should  not  be 
diminished  by  too  great  tension  or  twisting.  It  is  often  well  to  make 
a  pedicle  with  curved  margins,  which  will  sustain  a  certain  amount 
of  additional  stretching  without  injurious  pressure  upon  the  vessel 
walls.  In  transplanting  large  masses  of  tissue  the  main  arteries  and 
veins  of  the  graft  may  be  united  with  corresponding  vessels  of  the  part, 
under  reconstruction,  by  angiorrhaphy  or  phleborrhaphy.  The  work 
of  Carrel  has  shown  the  value  of  this  procedure. 

A  flap  which  is  too  large  can  easily  be  retrenched  at  the  time 
it  is  put  into  its  new  position,  but  a  small  flap  will  never  bear  much 
stretching,  to  increase  its  size,  without  danger  of  interfering  with 
its  nutrition.  The  gap  which  is  to  be  filled  looks  larger  than  it  really 
is,  because  of  retraction  of  its  edges.     When  these  edges  are  brought 


38  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

into  contact  with  the  margins  of  the  flap  by  sutures,  the  area  to 
be  covered  by  the  flap  is  considerably  lessened.  Skin  as  free  as 
possible  from  hair  should  be  chosen  for  plastic  procedures  unless 
it  is  desired  to  replace  an  eyebrow,  or  repair  a  part  of  the  face  ordinar- 
ily covered  by  the  beard. 

When  a  gap  is  to  be  closed  by  interpolation  or  parts  united  by 
approximation,  the  surfaces  should  be  freshened  by  such  free  incisions 
as  will  give  a  broad  surface  of  contact.  A  thin  raw  edge  gives  lit- 
tle opportunity  for  firm  union.  After  the  hemorrhage  has  been  con- 
trolled, approximation  should  be  made  by  sutures  which  will  hold  the 
parts  together  without  tension. 

In  the  formation  of  noses  and  ears,  the  surgeon  should  at  first 
be  satisfied  with  obtaining  a  bulky  semblance  of  the  organ.  A  more 
accurate  configuration  can  be  obtained  after  cicatricial  contraction 
has  taken  place.  It  is  unwise  at  the  first  operation  to  endeavor  to 
obtain  a  perfect  result  and  thereby  probably  use  too  little  tissue. 
In  extensive  operations  a  too  zealous  desire  for  immediate  correction 
of  deformity  may  cause  death  from  shock  or  bleeding. 

The  least  degree  of  scarring  will  be  obtained  after  healing  by  first 
intention;  hence  the  demand  for  perfect  asepsis.  It  is  difficult  to 
keep  parts  free  from  germs  if  near  the  nose,  eyes  or  mouth,  since 
contamination  occurs  from  the  fluids  escaping  from  these  organs. 
Therefore,  washing  the  parts  with  sterile  normal  saline  solution  or  a 
mild  antiseptic  solution  just  before  inserting  the  sutures,  and  again 
before  applying  the  dressings  will  be  found  very  serviceable  in  the 
prevention  of  sepsis. 

When  transplantation  without  a  pedicle  is  undertaken  the  tis- 
sues, which  are  to  be  employed,  must  be  kept  aseptic  and  warm  during 
the  interval  between  their  excision  from  the  normal  position  and  their 
insertion  into  the  new  locality.  Pieces  of  bone,  nerve  and  skin  thus 
emplo5^ed  should  be  wrapped  in  warm  aseptic  towels  or  kept  in  an 
aseptic  solution  of  about  105°  F.  The  so-called  normal  salt  solution, 
made  by  dissolving  sodium  chloride  0.6  per  cent,  in  water  and  steriliz- 
ing the  solution  by  boiling,  is  the  best  agent  for  this  purpose  because 
it  is  similar  in  specific  gravity  to  the  serum  of  the  blood.  Weak 
antiseptic  solutions  may  be  used,  but  strong  ones  damage  the  grafts. 

After  such  transplantation,  aseptic  rubber  tissue  or  oiled  silk 
should  be  placed  over  the  area  of  operation  and  an  aseptic  gauze  dress- 
ing applied.  I  usually  make  a  few  slits  in  the  rubber  tissue  with 
scissors  in  order  that  the  serum  oozing  from  the  seat  of  operation  may 
escape  through  the  tissue  and^  be  absorbed  by  the  overlying  gauze. 
This  form  of  dressing  keeps  the  wound  fairly  dry  and  yet  prevents  the 


PRINCIPLES  OF  PLASTIC  SURGERY  OF  THE  FACE  39 

gauze  from  coming  into  immediate  contact  with  the  wound  edges  and 
the  grafts.  Pulling  the  lips  of  the  wound  apart  or  displacing  the  flap 
when  the  dressing  is  removed  is  thus  avoided.  A  few  layers  of  gauze 
held  in  position  with  collodion  make  a  convenient  aseptic  dressing, 
less  bulky  than  an  ordinary  gauze  dressing.  It  cannot  be  used  with 
propriety,  however,  if  the  contraction  or  the  collodion  is  likely  to  drag 
the  eyelid  or  lip  out  of  position.  After  skin-grafting,  a  sterile  veil  of 
a  single  thickness  of  gauze  laid  over  the  grafts  and  extending  beyond 
the  edges  of  the  wound  answers  well  to  prevent  detachment  or  slipping 
of  the  grafts.  This  may  be  fixed  by  collodion  at  the  edges  and  should 
not  be  removed  for  about  eight  or  ten  days.  The  overlying  gauze 
dressing  may  be  changed  every  three  or  four  days.  J.  S.  Davis  and 
others  use  netting  coated  with  rubber  or  other  non-absorbent  material 
for  keeping  the  grafts  in  place  and  at  the  same  time  allowing  the  serum 
to  escape  into  the  sterile  overlying  gauze  dressing. 

If  gangrene  of  a  flap  does  not  occur  previous  to  the  fourth  day, 
the  integrity  of  the  transplanted  or  transferred  tissue  is  pretty  well 
assured.  A  grayish  and  pulpy  appearance  of  the  flap  with  sup- 
puration of  the  cuticle  indicates  moist  gangrene.  If  the  tissue  be- 
comes black  and  dry,  anemic  gangrene  has  occurred.  Gangrene  will 
to  a  greater  or  less  extent  interfere  with  the  success  of  the  plastic 
operation.  The  parts  in  dry  gangrene  should,  however,  be  left  un- 
disturbed in  the  hope  that  the  mortification  will  be  limited.  If  moist 
gangrene  occurs  it  is  probably  due  to  the  action  of  pathogenic  germs. 
Eather  active  irrigation  with  mild  antiseptic  solutions  and  frequent 
change  of  dressing  are  indicated.  This  is  not  the  case  in  dry  gangrene. 
The  gangrenous  portion  should  not  be  removed  by  cutting  away  the 
tissue  until  it  is  very  certain  where  the  process  will  stop.  Quite 
often  the  death  of  tissues  is  limited  to  the  edge  or  superficial  layers 
of  the  flap.  Some  tissue  in  the  center  or  on  the  lower  surface  of 
the  transplanted  or  transferred  flap  may  retain  vitality  and  will 
often  render  the  operation  more  successful  than  would  have  been  sup- 
posed from  the  appearance  when  gangrene  began.  Sometimes  the  flap 
becomes  blue  from  venous  engorgement  due  to  the  twist  in  the  pedicle; 
then  it  will  look  as  if  gangrene  was  about  to  occur.  The  venous  stasis 
may  be  great  enough  to  cause  gangrene.  Incision  of  the  flap  in  several 
places  may  drain  out  this  blood  and  save  the  tissues  from  sloughing. 

WOUNDS. 

Contusions  of  the  face  are  disfiguring  from  the  swelling  and  dis- 
coloration   which    thev    cause.     The    loose    subcutaneous    tissue    of 


40  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

the  eyelids  especially  permits  extensive  extravasation  of  blood,  after 
contused  wounds  in  the  vicinity  of  the  eyes.  The  puffy  swelling- 
disappears  in  a  day  or  two,  but  the  cutaneous  discoloration  lasts  for 
a  week  or  ten  days.  The  skin  over  the  extravasatecl  blood  is  at  first 
bluish-black,  but  gradually  becomes  greenish  and  then  yellowish,  be- 
fore assuming  its  normal  hue. 

A  similar  discoloration  of  the  forehead  may  be  seen  when  a  wound 
of  the  scalp  has  been  received,  because  the  extravasatecl  blood  gravi- 
tates downward  into  the  tissues  of  the  upper  part  of  the  face.  Sub- 
conjunctival ecchymosis,  giving  a  red  discoloration  to  the  white 
sclerotic  region  of  the  eye,  occurs  in  blows  received  upon  the  eyeball, 
in  rupture  of  conjunctival  vessels  from  coughing,  vomiting,  or  strain- 
ing at  stool,  and  in  fractures  of  the  orbital  plate  of  the  frontal  bone 
or  of  the  other  bones  which  take  part  in  the  construction  of  the 
orbital  cavity. 

Pressure  and  cold  compresses,  employed  for  a  few  hours  after  a 
contusion  has  been  received,  tend  to  arrest  the  subcutaneous  bleeding 
and  thereby  diminish  the  consecutive  tumefaction  and  discoloration. 
Pressure  probably  does  little  good  after  a  couple  of  hours.  The  cold 
applications  should  be  discontinued  at  the  end  of  eight  or  ten  hours; 
they  are  likely  to  interfere  with  the  process  of  absorption,  upon  the 
activity  of  which  the  removal  of  the  blood  and  inflammatory  desposits 
depends. 

In  cases  characterized  by  great  ecchymosis  numerous  minute  punc- 
tures of  the  skin  may  be  made,  through  which  the  blood  is  to  be 
squeezed  out  of  the  tissues.  Perfect  asepsis  must  be  maintained,  if 
this  means  is  adopted,  in  order  to  avoid  the  occurrence  of  suppuration 
and  conspicuous  scarring.  Solutions  of  ammonium  chloride  (gr. 
v-x  ad  §j),  tincture  of  arnica  and  similar  lotions,  used  to  hasten  the 
absorption  of  the  blood  and  the  return  of  the  skin  to  its  natural  color, 
probably  owe  their  reputation  largely  to  the  friction  employed  in 
their  use.  Rubbing  with  adeps  lanse.  or  other  ointment  is  probably 
beneficial  in  promoting  absorption.  Agnew  believed  that  surgical 
shock  greatly  delayed  removal  of  extravasated  blood;  and  advocated, 
in  addition  to  warm  and  stimulating  applications,  tonics  and  ample 
diet  to  hasten  absorjDtion.  Pugilists  at  times  paint  the  skin  with 
flesh  colored  cosmetics  to  conceal  the  black  and  blue  marks  due  to 
bruises. 

Incised  and  lacerated  wounds  must  be  rendered  aseptic  by  thor- 
ough cleansing  with  soap  and  water,  followed  by  the  application  of 
mild  antiseptic  solutions.  Anesthesia  will  often  be  required  to  enable 
the  surgeon  to  do  his  full  duty  in  this  respect.     The  scrubbing  brush 


PRINCIPLES  OF  PLASTIC  SURGERY  OF  THE  FACE  41 

must  be  vigorously  used  to  remove  all  dirt  and  septic  particles  from 
the  raw  surfaces.  Care  must  be  taken  to  keep  strong  antiseptic  solu- 
tions out  of  the  eyes,  nose,  and  mouth. 

Tissues  seeming!}'  devitalized  should  not  be  hastil,y  cut  away,  for 
the  free  blood  supply  of  the  face  enables  its  structures  to  sustain 
much  damage  without  the  induction  of  gangrene.  Heat  applied  bj' 
means  of  affusions  of  hot  sterilized  salt  solution  or  hot  antiseptic 
washes  will  aid  in  revivifying  damaged  skin.  The  temperature  of  the 
lotions  should  be  about  105°  F.  Dry  heat  may  also  be  used  by  means 
of  a  small  rubber  bag  containing  hot  water. 

The  approximation  of  the  wound  should  l^e  made  by  sutures  em- 
ployed in  accordance  with  the  principles  laid  down  in  the  previous 
chapter,  which  considers  the  closure  of  operative  wounds.  The  dress- 
ings there  detailed  are  also  to  be  adoj^ted.  When  sterilization  and 
neat  coaptation  are  evidenth'  impossible,  because  of  the  character 
of  the  wounds  and  their  multiplicit}^,  very  frequent  irrigation  of 
the  surface  of  the  face  will  wash  away  discharge  and  prevent 
septic  accumulations.  A  saturated  boric  acid  solution,  a  weak  licpor 
formaldehyde  lotion  (1  to  3000-5000),  or  normal  salt  solution  is  satis- 
factory.    The  lotion  should  be  used  about  every  two  hours. 

"When  actual  loss  of  skin  has  occurred  and  the  gap  cannot  be 
covered  by  sliding  or  transferring  flaps,  immediate  skin  grafting  b}' 
shavings  cut  from  the  thigh  or  arm  may  be  adopted.  It  is  necessary 
for  success  that  the  raw  surface  be  thoroughh"  sterilized  and  bathed 
with  hot  and  sterile  normal  salt  solution.  The  skin  shavings  cut 
from  the  thigh  with  a  razor  are  laid  while  warm  over  the  denuded 
surface  in  such  a  manner  that  their  edges  over-lap.  A  piece  of  sterile 
protective,  or  rubber  tissue  is  laid  upon  them  and  a  dry  gauze  dres- 
sing applied.  I  usually  cut  a  few  slits  in  the  protective  tissue  so  that 
any  serum  oozing  from  the  wound  may  find  opportunity  to  escape  to 
the  over-lying  chy  gauze.  Krause's  flaps  consisting  of  the  entire 
thickness  of  the  skin  may  be  successfully^  used,  if  perfect  asepsis  is 
obtained. 

The  edges  of  wounds  of  the  nasal,  auricular  or  tarsal  cartilages 
should  be  brought  together  b}'-  fine  sutures,  which  may  be  carried 
through  the  cartilages  if  necessary.  Often  the  skin  over  the  cartilage 
will  give  sufficient  hold  for  the  stitch. 

Local  emphysema  of  the  cellular  tissue  of  the  face  may  occur, 
when  the  lachrvmal  sac  is  ruptured,  or  the  frontal  or  maxillary  sinus 
or  the  ethmoid  cells  opened  by  fracture.  When  the  air  escapes  only 
into  the  loose  tissue  of  the  orbit,  protrusion  of  the  eyeball  and  crepi- 
tation, felt  on  palpation  of  the  ocular  region,  occur.     The  deformity 


42  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

from  the  swelling  due  to  air  in  the  connective  tissue  needs  no  treat- 
ment. Subcutaneous  rupture  of  the  duct  of  the  parotid  gland  has 
been  caused  by  blows  on  the  cheek.  The  saliva  may  then  burrow 
into  the  tissues  of  the  face  and  neck,  causing  an  emphysematous 
swelling  and  much  deformity.  Pressure  will  probably  be  the  only 
treatment  required  in  such  injuries. 

Gunshot  wounds  often  induce  great  facial  deformity  because  con- 
siderable areas  of  tissue  are  carried  away  by  the  missile.  Much  per- 
manent disfigurement  may  result  from  displacement  of  the  bones, 
actual  loss  of  tissue,  or  cicatricial  contraction  in  these  and  other 
injuries.  Powder  grains  imbedded  in  the  skin  should  be  picked  out 
otherwise  the  carbon  in  powder  will  leave  bluish  tattoo  marks.  The 
distortion  due  to  bony  lesions  must  be  prevented,  as  far  as  possible,  by 
accurate  replacement  of  fragments.  A  great  amount  of  power  may 
be  required  to  pry  up  depressed  fragments  or  alter  the  relation  of 
bones  driven  together  by  the  vulnerating  force. 

The  side  of  the  face  is  greatly  deformed  by  depressed  fracture 
of  the  zygomatic  arch.  The  depressed  portion  should  be  elevated 
with  a  lever,  introduced  through  an  incision  made  parallel  to  the 
margin  of  the  zygoma.  A  similar  elevation  of  bone  may  be  required 
when  the  anterior  wall  of  the  sinus  of  the  upper  jaw  has  been  crushed  in. 
Hooks-like  ice-tongs  have  been  used  to  lift  up  the  fractured  upper  jaw. 

In  extensive  osseous  injuries  the  bones  should  be  accurately  ad- 
justed and  held  in  position  if  necessary  by  chromicized  catgut  sutures, 
introduced  through  drill  holes.  Sterilized  bone  or  ivory  pegs  or 
steel  nails  and  tacks  may  be  employed  to  nail  the  bony  structures 
together,  if  sutures  are  not  effective.  The  nails  may  be  removed 
later  or  allowed  to  become  encysted;  bone  or  ivory  pegs  will  be  ab- 
sorbed, if  the  wound  remains  aseptic.  Teeth  knocked  out  should  be 
washed  with  mild  antiseptic  solution  and  replaced  in  the  socket  pre- 
viously sterilized.  The  adjoining  teeth  may  be  utilized  as  a  sort  of 
splint  to  which  the  loose  teeth  may  be  tied  or  wired.  Keeping  the 
mouth  bandaged  shut,  as  in  fracture  of  the  lower  jaw,  or  the  use  of  an 
interdental  splint  will  aid  in  maintaining  immobility  until  the  re- 
planted tooth  becomes  firm  in  its  bed.     This  requires  a  week  or  two. 

Bullet  wounds  of  the  face  should  seldom  be  probed.  Little  in- 
formation is  gained  with  the  probe  that  cannot  be  obtained  without 
it.  Such  wounds  are  usually  sterile  unless  they  open  one  of  the 
cavities  of  the  head.  The  surgeon's  object  should  be  to  obtain  prompt 
union  by  organization  of  the  moist  sterile  blood-clot  within  the  bullet 
track.  Exploration  with  the  probe  is  likely  to  interfere  with  this 
method  of  healing.     Extraction  of  the  ball  through  the  opening  of 


PRINCIPLES  OF  PLASTIC  SURGERY  OF  THE  FACE  43 

entrance  is  very  unlikely  to  be  possible.  Most  bullets  buried  in  the 
face  are  not  found.  Unless  the  situation  of  the  buried  missle  is 
apparent,  it  is  better  surgery  to  gain  primary  antiseptic  occlusion  of 
the  wound  with  a  gauze  pad  or  a  gauze  and  collodion  dressing.  A 
minimum  deformity  from  scar  is  obtained  if  union  without  suppura- 
tion occurs.  Any  redness,  swelling,  or  pain  pointing  to  sepsis  should 
be  met  by  immediate  opening  of  the  wound.  It  should  then  be 
S3'ringed  out  thoroughly  with  an  aseptic  solution  and  dressed  in  a 
manner  to  favor  drainage  of  fluids.  The  possibility  of  poisoning  by 
antiseptic  solutions  entering  the  mouth  or  esophagus  during  such 
syringing  should  not  be  forgotten. 

Punctured  wounds  should  be  managed  by  similar  occlusive  dress- 
ings, if  made  with  clean  and  smooth  instruments  probably  sterile. 
If  the  vulnerating  instrument  was  manifestly  septic  or  if  the  wound  at 
a  later  time  shows  signs  of  infection,  the  tissues  should  be  widely 
opened  and  sterilized,  as  in  those  parts  of  the  body  where  scarring  is 
not  objectionable.  A  properly  planned  incision  will  cause  less  dis- 
j&gurement  than  the  cicatricial  distortion  consequent  upon  a  neglected 
septic  wound. 


CHAPTER  V. 
GUNPOWDER   AND    LOCAL   DISCOLORATIONS.     TATTOOING. 

The  unburnt  powder,  imbedded  in  the  skin  and  subcutaneous- 
tissue  by  injuries  from  firearms  at  close  range,  leaves  permanent  blue 
stains  like  the  discolorations  obtained  in  tattooing  with  black  pig- 
ments. Coal  miners  and  those  injured  by  pieces  of  coal  often  present 
similar  disfigurements.  After  such  injuries  the  powder  or  coal  dust 
must  be  at  once  thoroughly  removed  from  the  tissues,  by  vigorous 
sci'ubbing  of  the  lacerated  or  burnt  surface  with  soap  and  hot  water 
and  a  brush.  Local  or  general  anesthesia  will  often  be  necessary. 
Attempts  to  remove  the  dust-like  particles  with  forceps  will  seldom 
be  successful. 

When  the  skin  has  healed  over  the  imbedded  carbon,  the  discolor- 
ation can  only  be  removed  by  excising  the  stained  area  or  tediously 
removing  each  minute  particle.  A  small  circular  punch  shaped  like 
the  end  of  a  watch  key  may  be  applied  over  each  blue  point,  or  croton 
oil  may  be  picked  into  the  discolored  skin  with  a  needle.  In  the 
latter  case  suppuration  will  probably  occur  and  cause  extrusion  of 
the  carbon.  The  minute  white  scars  will  be  less  disfiguring  in  a  white 
patient  than  the  tattoo  marks.  I  was  once  asked  to  remove  from 
the  forehead  of  a  Hindo  woman  the  tattooed  mark  of  her  caste.  I 
feared  that  the  white  scars  left  by  either  of  these  methods  would  be 
conspicuous  on  the  smooth  brown  skin.  I  told  the  patient  that  I 
would  make  experimental  trial  of  the  various  chemical  and  operative 
methods  for  this  purpose  on  her  arm  before  attacking  the  exposed 
surface  of  her  face.     She,  however,  did  not  return  for  treatment. 

The  combustive  destruction  of  the  imbedded  carbon  by  introducing 
a  red-hot  galvano-caustic  needle  has  been  proposed  for  removing  blue 
tattoo  marks.  I  do  not  know  what  effect  this  method  would  have  on 
mineral  pigments  but  it  seems  plausible  in  cases  of  powder  stains. 

Dermatologists  employ  chemical  means  to  remove  intentional 
tattooing,  but  the  discolorations  due  to  accidental  wounds  from 
firearms  or  coal  mining  injuries  are  probably  too  deep  for  the  success- 
ful application  of  chemical  solvents.  Ohmann-Dumesnil  says  that  he 
has  removed  the  pigmentation  in  tattooing  by  pricking  glyserole  of 
papaine  deeply  into  the  skin.     He  thinks  that  the  digestive  principle 

44 


GUNPOAVDER  AND  LOCAL  DISCOLORATIONS  45 

of  the  papaine  is  disseminated  about  the  pigment  particles  and  liber- 
ates them  from  the  enveloping  tissue;  and  that  the  finely  divided  carbon 
or  metallic  pigment  is  then  partly  absorbed  by  the  lymphatic  vessels 
and  partly  extruded  from  the  surface. 

Another  method  is  called  Variot's  plan.  In  this  a  concentrated 
solution  of  tannin  is  pricked  or  tattooed  into  the  deep  layers  of  the 
skin  at  the  spot  where  the  discoloration  is  situated.  A  stick  of  silver 
nitrate  is  then  firmly  rubbed  into  the  punctured  area.  The  skin  is 
not  wiped  off  until  the  little  wounds,  made  bj''  the  tattooing  needles 
of  the  surgeon,  show  as  black  points,  because  of  the  formation  of 
silver  tannate.  Inflammation  occurs,  scabs  form  and  on  the  removal 
of  the  scabs  in  a  couple  of  weeks  the  pigmentary  stain  is  gone.  A  red 
scar  remains  for  a  considerable  length  of  time.  Excision  of  each  spot 
is  probably  the  most  successful  method. 

Cicatricial  Distortions. 

The  special  deformities  of  the  eyelids,  nose  and  lips,  caused  by 
cicatricial  contraction,  will  be  discussed  in  detail  later  when  these 
portions  of  the  face  are  under  consideration.  Here  the  general 
topic  only  will  be  taken  up. 

Scars  unimportant  in  other  regions  are  unsightly  and  to  be  avoided 
upon  the  face.  Incisions  made  from  the  interior  of  the  mouth  will 
often  be  available  in  evacuating  abscesses  of  the  cheeks  and  lips. 
Thus  can  the  surgeon  obviate  cutaneous  scarring  in  a  certain 
number  of  abscesses  of  the  face.  The  disfiguring  scarring  due 
to  S5''philitic  ulcers  and  suppurating  gummy  tumors  is  always 
preventable  by  early  and  vigorous  treatment  with  large  doses  of 
mercury  and  potassium  iodide.  These  conditions  are  usually  ter- 
tiary manifestations.  They  demand  immediate  recognition  and  very 
active  management  on  the  part  of  the  surgeon,  because  here,  as  in 
syphilis  of  the  nervous  centers,  delay  and  inefficiency  lead  to  irrep- 
arable damage  to  the  tissues.  Yellow  iodide  of  mercur}-,  in  doses  of 
half  a  grain  or  more,  and  potassium  iodide,  in  twenty  or  thirty  grain 
doses,  are  the  remedies  I  prefer.  I  often  give  both  of  t^iese  drugs 
to  the  same  patient,  administering  the  mercur}"  before  each  meal  and 
the  potassium  salt  after  meals.  It  is  judicious  for  chemical  reasons 
to  have  an  interval  between  the  ingestion  of  the  two  iodides,  lest  a 
toxic  combination  should  be  formed  in  the  stomach.  The  doses 
should  be  as  large  as  necessary.  I  have  given  one  thousand  to  twelve 
hundred  grains  of  potassium  iodide  daily  in  syphilis  of  the  bones  of 
the  leg.      Ehrlich's  salvarsan  (dioxydiamidoarsenobenzene  dihydro- 


46  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

chloride)  given  in  appropriate  doses  seems  to  promise  most  valuable 
results  in  the  rapid  cure  of  syphilis.  Its  use,  in  combination  with  the 
Wassermann  reaction  to  test  the  patient's  freedom  from  the  disease 
after  treatment,  may  largely  supplant  that  of  mercury  and  iodine. 

Tuberculous  lymph  nodes  should  be  removed  by  a  properly  placed 
incision  before  they  soften  and  form  puriform  collections.  Sometimes 
the  tubercular  adenitis  may  be  so  treated  locally  and  generally  that 
the  swollen  gland  will  decrease  in  size  and  need  not  be  excised.  In 
the  face  and  neck,  however,  too  much  time  should  not  be  wasted  in 
this  hope,  since  the  scar  of  a  spontaneously  evacuated  tubercular 
abscess  is  puckered  and  uncomely. 

If  the  case  is  not  presented  to  the  surgeon  until  softening  has 
already  occurred,  incision,  with  thorough  curetting  and  the  appli- 
cation of  iodoform,  should  be  adopted  before  the  overlying  skin  has 
become  so  thinned  that  a  puckered  scar  is  likely  to  occur.  The 
very  thin  portion  of  skin  at  the  point  where  spontaneous  evacua- 
tion is  about  to  take  place  is  usually  too  much  devitalized  to  be  of 
service  for  holding  sutures,  and  may  as  well  be  trimmed  away  at  the 
time  the  abscess  is  curetted.  If  a  complete  removal  of  tubercular 
tissue  is  accomplished,  the  edges  of  the  incision  may  be  sutured  with 
a  reasonable  assurance  of  primary  union.  Very  often  such  a  satisfac- 
tory result  is  not  obtained.  The  earlier  the  operation,  however,  the 
less  danger  of  an  ugly  scar. 

A  tubercular  abscess  may  occasionally  be  drained  by  transfixing 
it  with  a  needle,  carrying  a  piece  of  silk,  wire,  or  silkworm  gut  which 
is  left  traversing  the  abscess  cavity  as  a  seton.  This  plan  is  valuable 
for  preventing  increase  in  the  puriform  collection  and  thinning  of 
the  skin,  when  the  radical  operation  has  to  be  delayed;  but  it  is  far 
inferior  to  the  prompt  evacuation,  curetting  and  suturing  of  the 
abscess. 

Excision  of  tumors  or  malignant  ulcers  of  the  face  should  be 
accomplished  by  means  of  incisions  so  chosen  that  cicatricial  con- 
traction will  do  little  harm  to  the  facial  outlines.  It  will  often  be 
necessary  to  fill  the  gap  left  by  the  excision  by  means  of  an  imme- 
diate plastic  operation  on  the  adjacent  skin.  The  extent  of  such 
operations  will  often  seem  to  the  inexperienced  almost  unjustified; 
but  the  final  result  will,  if  the  work  is  artistically  done,  prove  the 
value  of  transferring  cicatricial  tension  to  regions  where  it  will  cause 
no  distortion. 

It  is  usually  better  to  do  the  plastic  operation  at  the  time  the 
tumor  is  removed  than  subject  the  patient  to  a  second  operation 
after  the  original  wound  has  healed.     The  healing  can  be  hastened 


GUNPOWDER  AND  LOCAL  DISCOLORATIONS  47 

and  the  distortion  greatly  lessened  or  entirely  prevented  by  such  a 
primary  plastic  procedure.  Subsequent  operations  may  be  demanded 
to  neutralize  minor  disfigurements,  but  it  is  wise  to  obviate  the 
greater  part  of  the  deformity  at  the  time  of  the  original  c>peration. 

Malignant  disease  of  the  cheek  near  the  corner  of  the  mouth 
frequently  requires  a  considerable  portion  of  the  entire  thickness 
of  the  wall  of  the  oral  cavity  to  be  cut  away.  The  patient  will  be 
unable  to  open  his  mouth  when  healing  has  occurred,  unless  the  gap 
in  the  cheek  has  been  filled  with  tissue  from  some  other  locality. 
The  cicatrix  occurring  even  when  the  wound  has  not  been  sutured  will 
irresistibly  draw  the  jaws  together,  and  cause  a  cicatricial  lockjaw. 
This  complication  may  be  less  marked  when  the  wound  has  been 
allowed  to  granulate  than  when  sutures  have  been  used  to  get  primary 
union;  but  in  either  case  the  disfigurement  of  the  face  will  be  most  dis- 
tressing and  the  function  of  the  jaws  greatly  impaired. 

Osteotomy  of  the  lower  jaw  in  front  of  the  scar  tissue  will  give 
mobility  to  the  other  side  of  the  mouth,  but  will  not  alleviate  the 
external  deformity. 

Plastic  reconstruction  of  the  cheek,  called  meloplasty,  at  the 
time  the  malignant  growth  is  removed  is  a  proper  procedure. 

Bardenheuer^  has  cut  a  flap  from  the  forehead,  turned  it  down- 
ward and  sutured  it  in  the  gap  left  in  the  cheek,  with  its  skin  sur- 
face toward  the  interior  of  the  mouth.  The  pedicle  of  the  flap  lay 
along  the  side  of  the  nose,  and  was  divided  after  the  flap  became  at- 
tached in  its  new  position.  The  raw  external  surface  of  the  flap 
was  covered  by  a  flap  of  similar  size  cut  from  the  side  of  the  neck 
and  rotated  upward  by  a  sliding  movement.  By  these  maneuvers  the 
cheek  was  reconstructed  and  had  a  cutaneous  surface  on  both  its  inner 
and  outer  aspects.  The  gap  in  the  forehead  left  by  such  an  opera- 
tion may  be  grafted  at  once  with  Thiersch  skin  shavings. 

Another  method  of  meloplasty  is  that  in  which  a  flap  cut  from  the 
side  and  back  of  the  neck  is  bent  upward  and  thrust  through  an  inci- 
sion made  into  the  mouth  along  the  outside  of  the  lower  border  of  the 
lower  jaw.  It  is  then  stitched  to  the  edges  of  the  gap  left  by  the 
removal  of  the  diseased  structures.  The  skin  surface  of  the  flap, 
is,  by  this  maneuver,  used  to  represent  the  mucous  lining  of  the 
cheek.  The  raw  outer  surface  is  to  be  grafted  with  shavings  of  skin.  The 
denuded  area  in  the  cervical  region  is  grafted,  allowed  to  granulate, 
or  covered  in  by  a  further  plastic  operation.  The  pedicle  is  divided 
when  the  circulation  of  the  flaps  has  been  assured  by  communication 
with  the  vessels  of  the  region  to  which  it  has  been  transferred. 

^  Deutsche  medicinische  Wochenschrift,  Leipsic,  June  11,  1891. 


48 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


There  is  danger  of  adhesion  between  the  inner  surface  of  the 
cheek  and  the  gums,  when  both  have  been  freshened  by  operation  or 
by  sloughing.  In  such  cases  mucous  flaps  may  at  times  be  success- 
fully dissected  from  the  inside  of  the  two  lips  in  front  of  the  affected 
area,  displaced  backward  and  sutured  so  as  to  prevent  adhesion. 
There  is  no  danger  of  the  lips  in  front  becoming  adherent  to  the  gums, 
by  reason  of  the  utilization  of  these  flaps,  because  the  gums  oppo- 
site them  have  a  normal  mucous  covering.     I  have  satisfactorily  used 


Fig.  20. — Meloplasty  by  cervical  flap  and  buttonhole. 


mucous  flaps  in  the  mouth  in  a  similar  manner  when  adhesion  of  gum 
and  cheek  from  gangrene  has  needed  operative  relief. 

Prosthetic  appliances  of  celluloid,  wax  and  papier-mache  have 
been  quite  successfully  made  to  take  the  place  of  large  portions  of 
the  face  lost  by  injury  or  disease. 

■  {  The  most  disfiguring  injuries  of  the  face  met  in  civil  practice 
are  those  caused  by  burns.  The  cicatricial  contraction  occurring 
after  the  sloughing  of  deep  burns  produces  horrible  disfigurements. 
They  rival  the  distortions  due  to  gunshot  injuries  seen  in  military 
practice.     Ectropion  of  eyelids,  symblepharon,  ankyloblepharon,  ever- 


GUNPOWDER  AXD  LOCAL  DISCOLORATIOXS 


49 


sion  of  the  lower  lip,  dragging  the  chin  down  to  the  chest,  oblitera- 
tion of  the  nostrils  and  loss  of  the  ear  are  frequent  occurrences  from 
burning. 

Scars  may  become  rough  and  irregularly  elevated  b}'  an  abnormal 
development  of  fibrous  tissue,  caused  by  what  has  been  called  hyper- 
trophy of  the  scar. 

Keloid  degeneration  of  scars  is  quite  frequent  in  negroes,  and 
takes  place  also  in  the  white  race.  It  occurs  in  the  period  of  adoles- 
cence, not  in  the  very  young  or  the  middle  aged;  and  seems  to  be 
more  frequent  in  scars  left  by  suppurating  wounds.  This  curious 
form  of  tumor  has  been  observed  to  arise  not  only  from  scars  due  to 


Fig.  21. — Occlusion  of  nose,  eversion  of 
lips,  and  distortion  of  eyelids  due  to  sloughing 
from  bum  (Author's  patient.) 


Fig.  21a. — Same  as  figure  21,  after  several 
operations. 


burns,  syphilitic  ulcers  and  other  serious  lesions,  but  from  those  left 
by  leech-bites,  acne  pustules,  herpes  zoster,  small-pox,  and  even  fly- 
blisters.  Moullin^  says  that  after  small-pox  the  whole  face  may 
become  expressionless  b}"  keloid  transformation  of  the  skin  into  a 
rigid  mask  of  livid,  nodular,  and  furrowed  tissue. 

The  thickened  and  elevated  condition  of  a  scar,  to  which  the 
name  hypertrophied  scar  has  been  given,  is  a  less  conspicuous  deform- 
ity than  keloid  degeneration  of  a  cicatrix,  though  there  seems  to  be 
little  histological  distinction  between  the  two  conditions. 

The  bluish,  purplish  or  pink  nodules  and  ridges,  with  smooth  and 

^  Treatise  on  Surgery,  Second  American  Edition,  p.  178. 
4 


50  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

glossy  surface,  irregularly  radiating  from  a  central  point  or  line  make 
keloid  degeneration  of  the  face  very  disfiguring.  Some  of  the  out- 
lying spurs  of  the  growth  may  be  whiter  than  the  rest  of  the  tumor. 
In  the  negro  the  surface  of  the  keloid  tumor  is  lighter  in  color  than  the 
surrounding  skin. 

This  disease,  called  false  keloid  or  keloid  of  Alibert,  is  said  to  differ 
from  true  keloid,  also  called  morphea  or  keloid  of  Addison,  in  that  it 
occurs  only  when  a  scar  has  previously  existed.  True  keloid,  which 
is  a  very  rare  growth,  is  said  to  occur  where  the  skin  has  not  been  the 
seat  of  injury.  The  conditions  are,  however,  of  similar  appearance. 
Some  authors  believe  that  the  two  affections  are  practically  the  same, 


Fig.  22. — Keloid  tumors  arising  in  scars  of  neck,  after  abscesses  from  piercing  ears  for  rings. 

and  that  the  pre-existing  scar  in  true  keloid  may  have  escaped  ob- 
servation. Keloid  degeneration  may  occur  in  mucous  membrane. 
It  is  said^  that  Verneuil  has  seen  it  in  a  conjunctiva,  previously 
scarred  by  burning  with  sulphuric  acid. 

The  fibromas  and  myxo-fibromas  seen  in  the  lobule  of  the  ear  after 
perforation  for  earrings  are  alHed  to  keloid  degeneration.  They  occur 
most  frequently  in  negroes,  and  are  more  rapid  in  growth  than  other 
keloid  tumors. 

Removal  of  keloid  growths  is  often  followed  by  prompt  recur- 
rence. The  secondary  tumor  is  not  infrequently  larger  than  the 
original  one.  Some  surgeons  have  therefore  advised  against  excision. 
Warren^  attributes  the  tendency  to  recurrence  to  implication  of  the 

1  Dictionary  of  Practical  Medicine,  Christopher  Heath,  vol.  i,  p.  306. 
^  Trans.  Amer.  Surgical  Ass'n.,  1893,  p.  55. 


GUNPOWDER  AND  LOCAL  DISCOLORATIONS  51 

walls  of  the  blood  vessels  for  some  distance  beyond  the  borders  of 
the  tumor.  This  condition  would  seem  to  point  to  the  necessity  of  a 
thorough  extirpation  by  incisions  placed  at  a  considerable  distance 
from  the  growth  to  be  removed. 

Tiffany^  states  the  keloid  tumors  gradually  soften  and  finally 
disappear.  He  believes  that  the}^  will  go  away,  or  at  least  not  in- 
crease much,  after  the  patient  has  reached  the  age  of  twenty-five 
years.  He  reports  the  case  of  a  girl  of  eight  and  one-half  years  who 
had  received  eighteen  months  previously  burns  of  the  face,  arm, 
shoulder  and  breast.  The  scar  was  half  an  inch  thick  and  looked  like 
a  plate  of  cartilage.  Dr.  Tiffany  declined  to  operate.  When  the  girl 
was  twenty  years  old  the  keloid  condition  had  disappeared,  and  she 
had  "a  perfectly  white,  smooth,  movable  scar  over  the  face."  Ob- 
servation of  this  and  other  cases  has  led  Dr.  Tiffany  to  the  conclusion 
that  operations  for  the  relief  of  keloid  deformity  are  unwise  in  the 
young  of  either  the  white  or  black  race. 

Agnew  says  that  the  growth  of  keloid  tumors  is  always  limited 
and  that  the  disease  often  disappears  spontaneously.  He  advocates 
non-interference  unless  they  are  painful  or  sensitive  upon  contact. 
Under  such  circumstances  he  advises  a  repetition  of  blisters,  followed 
after  healing  by  frictions  with  iodine  or  mercurial  ointment  with  a 
small  amount  of  belladonna  ointment.  The  American  Text-book  of 
Surgery  says  that  removal  by  the  knife  or  caustics  should  never  be 
undertaken  while  the  growth  is  enlarging;  but  that  if  any  caustic  is 
used  fused  potassa  is  best.  Repeated  scarifications  or  multiple  elec- 
trolytic punctures  may  be  successful  in  causing  absorption  of  the 
keloid  growth.  The  scarifications  should  be  made  at  intervals  of 
about  one  centimeter  and  go  through  the  entire  thickness  of  the  tumor. 
The  use  of  the  X-ray  has  been  followed  by  improvement.  Kempf- 
records  a  case  of  a  woman,  aged  19  years,  who  had  keloid  tumors  of 
the  face,  which  disappeared  after  several  weeks'  treatment  by  hypo- 
dermic injections  of  extract  of  ergot.  Thiosinamin  has  been  advo- 
cated as  an  internal  remedy,  given  by  hypodermatic  injection  or  by 
the  mouth.     It  is  probably  without  value. 

Compression  has  been  used  to  lessen  the  deformity  of  elevated 
scars  and  keloid  masses.  Unna  cured  a  keloid  tumor  following  burn 
by  pressure  continued  for  two  and  a  half  months.^  Mercurial  oint- 
ment was  applied  and  held  in  position  by  strips  of  adhesive  plaster; 

1  Trans.  Amer.  Surgical  Ass'n.,  1893,  pp.  77,  78. 

2  Louisville  Med.  News,  Oct.  12,  1878,  quoted  by  J.  Collins  Warren,  Trans. 
Amer.  Surg.  Ass'n,  1893,  p.  55. 

^  Warren,  loc.  cit.,  p.  69. 


52  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

collodion  was  used  over  this  and  the  entire  dressing  allowed  to  remain 
for  a  week.  Iodide  of  lead  ointment  has  been  employed  instead  of 
mercurial  ointment.  Acetate  of  lead  and  collodion  in  the  proportion 
of  one  to  five  have  been  used  as  an  application  to  keloid  deformities. 
The  elastic  bandage  has  been  employed  to  make  pressure  when  the 
locality  has  been  suitable.  Warren  has  suggested  inoculation  with 
the  virus  of  erysipelas,  because  keloid  tumors  belong  to  the  connective 
tissue  growths  and  because  Volkmann  has  detailed  a  case  apparently 
cured  by  an  attack  of  erysipelas.  The  severity  of  the  remedy  in 
Warren's  opinion  would  be  a  deterrent  to  the  surgeon. 

Now  that  the  toxins  of  the  erysipelas  streptococcus  and  the  bacillus 
prodigiosus  are  prepared  for  hypodermic  use  in  the  treatment  of 
sarcoma,  I  would  be  perfectly  willing  to  treat  keloid  disease  by  sub- 
cutaneous injections  of  these  bacterial  products. 

Panas  recommends^  compression  for  elevated  scars,  not  keloid  in 
character.  It  should  be  continued  for  months.  The  actual  cautery 
may  be  useful  in  removing  small  elevated  scars  of  long  standing,  but 
I  believe  the  knife  to  be  better.  Dr.  J.  Wm.  White  has  reported^  a 
case  of  hypertrophied  scar,  which  may  perhaps  have  been  keloid  disease 
which  improved  under  the  administration  of  extract  of  thyroid  gland 
and  local  applications  of  collodion. 

If  excision  is  adopted  as  the  treatment,  the  incisions  should  go 
down  to  the  muscular  aponeurosis  and  be  one  or  two  centimeters 
beyond  the  apparent  margin  of  the  disease.  In  thus  treating  keloid 
of  the  face,  the  cuts  should  be  so  placed  as  to  give  the  best  approxi- 
mation of  the  wound  edges  and  get  as  little  dragging  of  the  surround- 
ing parts  as  possible.  .Union  by  first  intention  should  be  secured. 
If  the  gap  is  too  great  for  coaptation,  skin  shavings  or  grafts  should  be 
grafted  on  the  surface,  or  some  plastic  procedure  should  be  adopted  as  is 
done  after  excision  of  malignant  tumors  of  the  face.  The  possibility 
of  keloid  change  occurring  in  all  the  incisions  must  be  remembered 
when  such  procedures  are  undertaken.  Under  some  circumstances  it 
may  be  better  to  wait  a  few  years  for  the  natural  softening  and  dis- 
appearance of  the  keloid  tumor;  or  to  adopt  some  of  the  non-operative 
means  of  treatment. 

1  myself  usually  excise  the  elevated  scar  freely  if  this  can  be 
done  without  cutting  the  tissues  of  the  face  too  extensively.  The 
incisions  must  be  kept  as  far  as  possible  from  the  borders  of  the 
tumor. 

Cicatricial  tissue  and  the  healthy  skin  may  be  stretched  by  re- 

'  Warren,  loc.  cit.  p.  66. 

2  University  Medical  Magazine,  Aug.,  1895,  p.  812. 


GUNPOWDER  AND  LOCAL  DISCOLORATIOXS  53 

peated  and  long  continued  efforts  to  do  so.  Surgeons  often  pay  too 
little  attention  to  this  fact  in  attempting  to  relieve  deformity.  If 
the  scar  and  skin  vceve  subjected  to  previous  systematic  stretching, 
plastic  operations  would  perhaps  be  more  successful. 

Close  approximation  of  wounded  parts  and  union  by  first  inten- 
tion lessen  the  amount  of  scar  tissue  because  they  encourage  regenera- 
tion of  skin,  muscle  and  fascia.  The  redness  and  thickening  from 
inflammatory  exudate  which  remains  after  wounds  have  united  slowly 
disappears  and  needs  no  treatment.  I  often  advise  patients  with  such 
wounds  of  the  face  to  rub  a  little  adeps  lanae  into  the  surface  of 
the  scar  twice  a  day.  This  probably  hastens  the  absorption  of  the 
exudate.  Too  much  friction,  especially  if  used  without  an  oleaginous 
application,  may  cause  irritation  during  the  time  of  its  continuance 
and  perhaps  thus  render  the  scar  red  and  more  conspicuous. 

The  deformit}'  occasioned  by  depressed  scars  is  sometimes  due  to 
adhesion  of  the  skin  to  underlying  fascia  or  bone,  sometimes  to  the 
puckered  condition  of  the  cicatrix,  sometimes  to  the  accumulation  of 
thickened  epidermis  along  the  edges  of  the  depression.  I  recently 
operated  upon  a  boy  who  had  had  necrosis  of  the  malar  bone  when  an 
infant,  which  left  a  depressed  scar  below  the  outer  canthus  of  the 
eye,  causing  ectropion.  The  cicatricial  tissue  evidently  extended 
down  to  the  bone  to  which  the  skin  at  the  bottom  of  the  scar  was,  so 
to  speak,  anchored.  Tubercular  abscesses  are  apt  to  leave  ugly  scars 
because  of  the  manner  in  which  the  skin  over  the  abscess  is  thinned 
and  devitalized  before  spontaneous  evacuation  occurs.  Early  opera- 
tive evacuation  of  the  puriform  fluid  or  enucleation  of  the  soften- 
ing glands  by  a  well  placed  incision  will  often  prevent  the  unseemly 
scarring.  Scars  from  pustular  acne  become  more  disfiguring  by  accu- 
mulation of  the  horny  layer  of  epithelium  about  them. 

Unna  advises^  in  depressed  scars  friction  of  the  skin  with  finely 
powdered  calcium  carbonate  which  by  attrition  removes  or  prevents 
epithelial  accumulation.  This  "marble  dust"  ma}'-  be  mixed  with 
powdered  soap,  sulphur,  or  other  ingredient  and  is  applied  with  a  sponge. 
The  skin  is  rubbed  or  polished  with  the  preparation  for  ten  or  fif- 
teen minutes  once  or  twice  a  day  for  several  months.  The  disfigur- 
ing pits  of  smallpox  ma}'  be  treated  in  a  similar  manner. 

The  unsightliness  of  depressed  or  irregular  scars  may  be  lessened 
by  surrounding  them  by  an  elliptical  incision,  under-cutting  the 
integument,  abrading  the  surface  of  the  scar,  and  then  drawing  the 
loosened  skin  over  the  cicatrix  by  neath'  applied  sutures.     This  de- 

^  Vierteljahr  fur  Derm,  uiid  Syph.    viii,  508,  quoted  by  Warren. 


54  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

vice  hides  the  uncomely  scar  tissue  and  elevates  the  surface  a  little. 
The  linear  cicatrix  is  very  inconspicuous,  if  properly  made. 

Mr.  Adams^  treats  depressed  scar  by  cutting  loose  the  deep  at- 
tachments with  a  tenotome  introduced  at  one  of  more  points,  everting 
the  sunken  tissue  and  maintaining  the  eversion  by  two  harelip  pins 
introduced  at  right  angles  to  each  other,  so  as  to  hold  up  the  elevated 
integument.  The  pins  are  kept  in  place  about  three  days.  Par- 
affin may  be  used  to  elevate  sunken  tissues  after  separating  them  from 
underlying  parts.  It  is  injected  when  liquefied  by  heat  and  moulded 
into  shape  before  it  cools. 

Sometimes  scar  tissue  is  disfiguring  because  it  is  much  whiter  than 
the  surrounding  skin.  It  has  been  suggested  that  such  unpigmented 
scars  be  colored  by  tattooing  with  pigments.  It  is  difficult  to  imitate 
successfully  the  tint  of  the  human  skin.  A  mixture  of  barium  sul- 
phate, yellow  ochre  and  water  has  been  proposed.  Paschkis^  says 
that  a  pigment  which  will  give  the  color  of  normal  skin  has  not  been 
found.  He  recommends  that  when  atrophy  of  pigment  exists  in 
portions  of  the  face,  as  in  vitiligo,  the  surrounding  pigmented  or  over- 
pigmented  areas  be  decolorized.  This  may  be  done  by  applying 
weak  solutions  of  corrosive  sublimate  (gr.  iii — ^v.  ad.  f§i)  salicylic 
acid  plaster,  or  some  one  of  the  agents  employed  by  dermatologists  to 
remove  freckles  and  pigmented  spots.  The  pigmentation  is  apt  to 
return  in  all  cases,  but  the  removal  of  the  discoloration  can  be  repeated 
from  time  to  time.  This  method  may  in  some  circumstances  be  avail- 
able to  disguise  the  whiteness  of  unpigmented  cicatrices. 

Paschkis  says  that  tattooing  with  cinnabar  gives  a  satisfactory 
result  when  after  plastic  operations  on  the  lips  it  is  desired  to  give  the 
intense  red  of  the  normal  mucous  membrane. 

^  Wm.  Adams,  Finger  Contraction  and  Depressed  Cicatrices,  p.  70,  London, 
1879. 

2  Cosmetics,  New  York,  1891,  p.  37. 


CHAPTER   VI. 

FISTULES,  FISSURES,  ENCEPHALOCELE,  ATROPHY  AND 
HYPERTROPHY. 

Congenital  fistules  and  fissures  of  tlie  face  and  neck  occur  because 
of  imperfect  closure  of  the  branchial  clefts  of  the  embryo.  When  the 
union  of  the  two  surfaces  is  imperfect  through  a  considerable  area,  a 
fissure  remains.  When  the  defective  closure  is  more  limited,  a  fistule 
or  sinus  is  left  as  a  relic  of  the  branchial  cleft.  The  term  congenital 
fistule  is  often  employed  to  describe  such  a  branchial  canal  with  a 
single  orifice.  The  term  congenital  sinus  seems  to  me  more  appro- 
priate. The  word  fistule  should  be  restricted  to  channels  connecting 
the  surface  with  a  cavity  or  duct  or  to  those  connecting  two  cavities 
or  ducts.  The  partial  closure  of  branchial  fistules  before  birth  may 
give  rise  to  the  dermoid  cysts  of  the  nose  and  other  parts  of  the  face, 
which  are  occasionally  seen.  The  pathology  of  these  cysts  is  similar, 
it  is  said,  to  that  of  the  accjuired  retention  cyst  due  to  closure  of  a 
sebaceous  duct,  which  is  seen  in  adults. 

Congenital  fissures  of  the  face  occur  especially  at  the  corner  of  the 
mouth  (macrostoma),  in  the  cheek,  eyelid  and  lip  (harelip).  They 
give  excellent  opportunity  for  reparative  surgery,  though  most  of  the 
forms  except  harelip  are  comparatively  rare. 

Congenital  fistules  are  seen  on  the  surface  of  the  cheek,  nose,  ear 
and  neck.  Sometimes  the  branchial  cleft  is  so  nearly  obliterated  that 
the  surface  of  the  skin  shows  merely  a  depression  or  pit,  instead  of  a 
sinus,  fistule  or  cleft.  Irregularity  in  the  closure  of  the  mandibular 
fissure,  for  example,  causes  macrostoma  when  its  edges  vmite  to  too 
little  an  extent  or  microstoma  when  to  too  great  an  extent. 

Acc^uired  facial  fistules  occur  ciuite  frequently  in  connection  with 
the  duct  of  the  parotid  gland.  They  are  caused  by  impaction  of  cal- 
culi, fish  bones  and  other  foreign  bodies,  or  as  the  result  of  wounds, 
suppuration  or  ulceration  of  the  cheek.  An  abscess  or  sloughing  of 
the  tissues  in  the  parotid  region  occasionally  causes  a  similar  salivary 
fistule  by  establishing  an  abnormal  communication  between  the  paro- 
tid gland  tissue  and  the  cutaneous  susface,  behind  the  proximal  end 
of  the  parotid  duct.  Salivary  fistules  also  occur  in  connection  with 
the  sublingual  and  submaxillary  glands  and  their  ducts. 

55 


56  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

Salivary  fistules  are  liable  to  be  mistaken  for  sinuses  due  to  necrotic 
bone  or  diseased  teeth.  The  escape  of  transparent  fluid,  giving  the 
chemical  reaction  of  saliva  and  increased  in  amount  during  mastica- 
tion will  render  the  differentiation  easy.  The  saliva  escaping  from  an 
ulcerating  lobule  may  burrow  under  the  integument  for  some  distance 
before  it  is  discharged  through  an  opening  upon  the  surface;  or  the 
secretion  so  escaping  from  the  gland  may,  if  there  is  no  external 
orifice,  cause  the  formation  of  a  cystic  tumor.  Bryant^  has  seen  in 
three  patients  parotid  salivary  fistule  situated  behind  the  angle  of  the 
jaw.  Agnew  says^  he  has  seen  a  congenital  salivary  fistule  situated 
on  the  anterior  part  of  the  helix  of  the  auricle.  It  seems  possible  that 
this  may  have  been  a  branchial  fistule,  mistaken  for  a  salivary  fistule. 
Mason^  speaks  of  subcutaneous  rupture  of  the  duct  of  the  parotid 


Fig.  23 — Disfiguring  furrow  in  forehead  from  empyema  of  frontal  sinus,  followed  by  necrosis. 
Deformity  relieved  by  transplanting  bone  graft  from  tibia.      (Author's  patient.) 

gland  from  traumatism,  causing  emphysematous  swelling  of  the  face 
and  neck.  The  same  author  records  an  instance  of  nine  or  ten  minute 
salivary  fistules  situated  over  the  parotid  gland.  I  once  saw  a  patient 
with  obstruction  of  the  parotid  duct  who  had  a  transudation  of  fluid 
on  the  skin  over  the  duct.     It  was  not  tested  for  the  salivary  reaction. 

Fistules  of  the  face  occur  subsequent  to  suppurative  inflammations 
of  the  frontal  sinus,  the  maxillary  sinus  and  the  lachrymal  sac  and 
gland.  The  history  of  the  case  and  the  location  of  the  cutaneous 
orifice  will  usually  indicate  the  pathological  condition  underlying 
the  disfiguring  lesion,  though  the  opening  may  be  situated  at  quite  a 
distance  from  the  original  disease. 

Fistulous  tracks  running  through  the  cheek  or  neck  into  the  mouth 
are  uncomely  and  may  result  from  suppuration  about  the  roots  of 
diseased  teeth.     In  such  dental  inflammations  care  should  be  observed 

'  Practice  of  Surgery,     Fourth  Amer.  Edition,  p.  417. 

^  Principles  and  Practice  of  Surgery,     Second  Ed.,  vol.  i,  p.  390. 

^Surgery  of  the  Face,  p.  61. 


FISTULES,  FISSURES,  ENCEPHALOCELE  AND  ATROPHY         57 

to  prevent  external  pointing  of  the  abscess.  Hot  applications  should 
not  be  applied  externall5^  Early  incision  of  the  gum,  removal  of  the 
filling  from  the  diseased  tooth,  or  drilling  into  the  pulp  cavity  will 
often  relieve  intense  pain  and  prevent  external  disfigurement.  Oral 
fistules  due  to  sloughing  of  the  buccal  tissues  are  not  common. 

Sinuses  are  not  infrequently  found  in  the  face  because  foreign 
bodies  have  remained  embedded  in  the  tissues  after  gunshot  wounds 
and  other  injuries.  Mason  refers^  to  a  case  in  which  a  piece  of  a  tobacco 
pipe  three  inches  long  had  been  imbedded  in  the  cheek  for  years. 
Necrotic  bone  from  phosphorus  poisoning  or  syphilis  and  tuberculous 
or  actinomycotic  abscesses  will  cause  deformity  by  reason  of  the  sup- 
purating sinuses  and  their  irregular  cicatrization.  Imperfectly  erupted 
teeth  dying  within  the  jaw  cause  cloacae  in  the  bone  and  sinuses  in 
the  overlying  tissue.  I  once  operated  on  an  aged  woman  who  had 
been  disfigured  with  sinuses  near  the  angle  of  the  jaw  for  years.  After 
chiselling  into  the  lower  jaw  along  a  small  orifice  in  the  bone  I  found  an 
unerupted  molar  tooth  lying  horizontally  within  the  osseous  tissue. 
It  had  never  been  erupted. 

The  treatment  of  fistules  and  sinuses  depends  on  their  cause. 
Dead  bone  and  foreign  bodies  must  be  removed  and  the  resulting  scars 
made  as  comely  as  possible  by  well  selected  incisions.  The  depressed 
and  irregular  cicatrices  that  sometimes  occur  from  spontaneous  or 
operative  openings  may  be  dealt  with  as  suggested  under  cicatricial 
distortions. 

Fistules  of  the  parotid  duct  are  seldom  closed  successfully  until 
the  current  of  saliva  has  been  diverted  into  the  mouth  by  constructing 
a  free  opening  in  the  mucous  membrane  of  the  cheek.  The  exact 
position  of  the  oral  opening  is  not  important,  if  it  is  so  made  as  to 
remain  sufficiently  patulous  to  always  conduct  the  saliva  into  the 
mouth. 

If  there  is  danger  of  cutting  the  duct  in  operations  on  the  face, 
its  position  may  be  made  distinct  by  inserting  a  bristle  or  small  probe 
into  the  duct  from  its  orifice,  opposite  the  second  upper  molar  tooth, 
before  the  facial  incisions  are  made.  If  the  duct  of  the  parotid  gland 
has  been  accidentally  divided  in  operations  on  the  face,  the  device 
advised  by  Moullin-  to  prevent  the  formation  of  a  salivary  fistule  may 
be  adopted.  He  directs  that  the  wound  be  extended  into  the  mouth, 
and  ''A  catgut  suture  passed  through  the  mucous  membrane  of  the 
cheek  and  the  adjacent  wall  of  the  duct  on  either  side  and  knotted  on 
the  oral  surface."     The  skin  is  then  closed  and  covered  with  collodion. 

'  Surgery  of  the  Face,  p.  15. 

^  Moullin's  Treatise  on  Surgery,  Second  Amer.  Edition,  p.  745. 


58  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

The  purpose  of  this  operation  is  to  establish  an  opening  into  the  mouth 
at  the  point  of  injury  to  the  duct. 

When  a  salivary  fistule  exists  on  the  cheek  and  cauterization  has 
failed  to  obliterate  the  cutaneous  opening,  an  operative  procedure  is 
demanded.  Horner's  method  consists  in  cutting  out  a  large  disk 
of  the  diseased  tissues  with  a  saddler's  punch  carried  through  the 
entire  thickness  of  the  cheek.  The  circular  hole  left  is  closed  externally 
with  cutaneous  sutures,  while  the  saliva  escapes  from  the  end  of  the 
duct  into  the  unclosed  opening  on  the  oral  surface  of  the  cheek.  A 
seton  may  be  passed  through  the  external  orifice,  carried  obliquely 
into  the  mouth,  and  worn  until  a  large  internal  opening  has  been 
established.  The  outer  opening  is  then  closed  as  in  Horner's  more 
expeditious  method. 

Salivary  drainage  into  the  buccal  cavity  above  the  fistule  may 
be  established  in  some  instances  by  carrying  a  thread,  by  means  of 
a  curved  needle,  around  the  duct  from  the  mucous  surface  of  the 
cheek  without  perforating  the  skin.  The  ligature  is  then  tied  within 
the  mouth  and  allowed  to  ulcerate  through  the  duct  and  the  mucous 
membrane,  thus  forming  a  fistulous  opening  within  the  mouth  above 
the  point  at  which  the  cutaneous  fistule  is  situated.  The  saliva  neces- 
sarily escapes  from  the  opening  nearer  the  secreting  gland;  and  that 
is  the  intra-oral  one.  The  cutaneous  opening  is  then  closed  by  paring 
the  edges  deeply  and  suturing.  The  incisions  to  freshen  the  edges  of 
the  fistule  may  be  carried  through  the  entire  thickness  of  the  cheek. 
Sometimes  a  flap  operation  may  be  demanded  to  close  the  opening 
securely.  The  placing  of  the  thread  around  the  duct  is  performed 
with  more  accuracy  if  a  bristle,  filiform  bougie,  or  the  canaliculus 
probe  used  by  ophthalmic  surgeons,  has  previously  been  introduced 
into  the  duct  to  show  its  exact  location.  In  some  cases  the  duct  can 
be  advantageously  slit  up  with  scissors  from  the  mucous  surface 
and  the  edges  of  the  mucous  membrane  lining  it  attached  to  the  inner 
wall  of  the  cheek  with  sutures  in  such  a  manner  as  to  prevent  closure 
of  the  new  orifice.  Another  method  is  to  dissect  a  portion  of  the  duct 
free  from  the  surrounding  structures  and  to  turn  its  end  into  the 
mouth  by  a  plastic  operation.  The  incisions  are  made  principally 
or  entirely  on  the  mucous  surface. 

Salivary  fistules  connected  with  lobules  of  the  secreting  gland 
and  not  with  the  duct  of  the  entire  gland,  may  be  remediable  only  by 
dissecting  out  the  portion  of  glandular  tissue  supplying  the  saliva. 

Fistule  of  the  frontal  sinus  due  to  suppuration  within  that  mucous 
cavity  may  occur  in  the  forehead,  or  under  the  eyebrow  near  the  root 
of  the  nose.     These  fistules  can  seldom  be  closed  until  free  drainage 


FISTULES,  FISSURES,  ENCEFHALOCELE  AND  ATROPHY         59 

downward  into  the  nose  has  been  established;  though  sometimes  a 
free  opening  made  with  a  drill  or  nasal  trephine  into  the  sinus  under 
the  inner  end  of  the  eyebrow  may  suffice  for  irrigation  and  drainage. 
To  accomplish  drainage  into  the  nose  a  free  incision  should  be  made  in 
the  forehead,  parallel  if  possible,  to  the  cutaneous  wrinkles  of  that 
region,  necrotic  bone  removed  and  the  sinus  thoroughly  curetted  and 
disinfected.  A  drill  should  then  be  driven  from  the  sinus  downward  into 
the  nasal  chambers  and  a  rubber  drainage  tube  left  in  the  canal  thus 
made.  It  is  probably  wiser  to  at  first  leave  the  tube  protruding 
through  both  the  frontal  opening  and  an  anterior  naris. 

Daily  irrigation  of  the  sinus  and  drainage  canal  with  normal 
salt  solution  or  mild  antiseptic  lotions  should  be  made.  When  the 
discharge  of  pus  has  nearly  ceased  and  the  drainage  downward  is  well 
established,  the  tube  may  be  shortened  so  that  it  does  not  protrude  from 
the  forehead,  and  plastic  closure  of  the  frontal  opening  may  be  at- 
tempted. This  is  to  be  done  by  simple  approximation,  after  fresh- 
ening of  the  margins  of  the  orifice,  or  by  a  flap  of  skin. 

An  osteoplastic  flap  might  be  chiseled  from  the  surrounding 
periosteum  and  bone  and  laid  over  the  opening  by  twisting  or  turning 
upside  down,  if  it  is  deemed  wise  to  attempt  to  reconstruct  the  ante- 
rior wall  of  the  frontal  sinus.  It  often  requires  prolonged  treat- 
ment of  the  frontal  sinus  with  antiseptic  and  astringent  washes  to 
cure  the  suppurative  inflammation  of  the  lining  mucous  membrane. 
Until  this  membrane  is  comparatively  healthy,  successful  plastic  clos- 
ure of  the  fistule  is  hardly  possible. 

In  intractable  cases  of  frontal  fistule,  it  is  proper  to  make  a  large 
incision  and  chisel  away  the  entire  anterior  wall  of  the  sinus.  This 
operation  gives  access  to  the  diseased  mucous  membrane  and  may 
enable  the  surgeon  to  bring  the  suppuration  to  an  end.  The  conse- 
quent scarring  will  have  to  be  corrected  as  far  as  possible  by 
subsequent  cosmetic  operations.  In  one  of  my  patients  the  pus  had 
burrowed  and  made  a  tract  through  the  bone  under  the  eyebrow. 
This  caused  ectropium  and  exposed  the  cornea,  which  became  inflamed 
from  want  of  protection.  I  was  obliged  to  turn  a  flap  from  the 
forehead  downward  to  correct  the  ectropium  and  protect  the  cornea. 

Fistules  of  the  antrum  of  the  upper  jaw  are  rare,  because  puru- 
lent accumulations  are  apt  to  be  evacuated  spontaneously  into  the 
nose  or  mouth  rather  than  upon  the  cheek.  Empyema  of  the  antrum 
should  be  treated  by  catheterization  through  the  normal  opening  in  the 
middle  meatus  of  the  nose;  by  perforation  with  a  drill  introduced 
into  the  nostril  and  carried  through  the  bone  below  the  inferior  turbi- 
nated bone;  or  by  boring  through  the  front  wall  of  the  upper  maxilla 


60  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

just  above  the  canine  tooth.  If  a  molar  tooth  is  diseased  it  may  be 
extracted  and  access  obtained  through  the  tooth  socket.  A  good 
tooth  should  not  be  sacrificed.  The  opening  thus  made  in  the  mouth 
gives  good  drainage  downward  and  should  be  kept  open  by  a  tent  or 
plug  for  several  weeks.  Drainage  is  necessary  before  any  fistule  on  the 
cheek  can  be  expected  to  close.  Chronic  suppuration  may  demand 
thorough  exposure  and  drainage  of  the  accessory  sinuses  of  the  nose  by 
chisseling  away  the  bone  after  the  methods  of  Killian  and  others. 

Fistules  of  the  lachrymal  sac  demand  dilatation  of  the  nasal 
duct  and  sometimes  the  introduction  of  a  soluble  or  a  metal  style. 
Soluble  styles  of  raw  hide  have  been  satisfactory  in  my  hands  as 
dilators  of  the  nasal  duct.  Downward  drainage  must  be  maintained 
and  the  mucous  membrane  brought  to  a  fairly  normal  condition  before 
frontal,  antral,  or  lachrymal  empyema  can  be  with  certainty  cured. 
Any  coincident  nasal  disease  tending  to  keep  up  the  trouble  should  be 
efficiently  treated. 

Congenital  fissures,  fistules  and  sinuses  must  be  operated  upon 
in  such  a  manner  as  will  create  raw  surfaces,  which  may  be  approxi- 
mated so  as  to  establish  the  normal  contour.  The  operations  for 
harelip  show  the  devices  available  for  this  purpose. 

Cerebral  Meningocele,  Encephalocele,  Hydrencephalocele. 

These  congenital  protrusions  of  the  cranial  contents  through 
openings  in  the  skull  are  usually  fatal  in  early  life  from  encephal- 
itis due  to  traumatism  or  to  infection  after  ulceration.  At  times, 
however,  concentric  ossification  at  the  edges  of  the  bony  opening  and 
shrinkage  of  the  tumor  may  lead  to  a  spontaneous  cure  in  meningocele 
and  simple  encephalocele.  When  a  cavity  communicating  with  the 
ventricles  exists  within  the  tumor  (hydrencephalocele)  this  result  is 
practically  unknown.  The  facial  deformity  resulting  from  the  pres- 
sure of  the  tumor  may  under  certain  circumstances  be  a  factor  in 
inducing  the  parents  to  consult  a  surgeon,  though  the  child's  life 
is  not  threatened  by  the  size  of  the  protrusion  or  its  progressive 
enlargement. 

Compression,  tapping,  injection  of  irritating  fluids,  removal 
by  elastic  ligature,  and  excision  with  the  knife  have  been  advocated 
and  employed  in  treating  these  conditions.  Compression  and  incision 
seem  to  have  been  the  most  satisfactory;  though  the  elastic  ligature 
and  tapping,  with  injection  of  iodine  or  iodine  combined  with  potas- 
sium iodide,  have  been  successfully  adopted.  Excision  seems  most 
valuable  theoretically,  but  the  difficulty  of  maintaining  asepsis  in 
the  facial  region  of  an  infant  may  nullify  this  opinion.     Excision 


FISTULES,  FISSURES,  ENCEPHALOCELE  AND  ATROPHY         61 

would  perhaps  be  a  less  serious  matter  in  meningocele  than  in  enceph- 
alocele;  though  there  is  probably  little  difference  in  the  risk  as  it 
depends  on  the  occurrence  of  infection  much  more  than  on  the  charac- 
ter of  the  tissue  protruding.  Pilcher  has  successfully  operated  by 
osteoplastic  flaps  on  an  infant  with  an  anterior  encephalocele."- 


Fig.   24. — Encephalocele.      {Dr.  Morris  B.  Miller's  case.) 

Deficiency  and  Atrophy  of  the  Bones  of  the  Face. 

Somewhat  allied  to  the  conditions  just  discussed  are  those  cases 
in  which  considerable  portions  of  the  bones  constituting  the  forehead 
and  face  are  congenitally  deficient.  In  the  present  discussion  we  have 
to  consider  those  cases  only,  in  which  the  deviation  from  the  normal 
is  moderate.  Monstrosities  while  interesting  teratologically  are 
beyond  the  reach  of  cosmetic  surgery.  Lannelogue  and  Menard 
divide  congenital  atrophies  of  the  face  into  those  of  embryonic  origin, 
which  are  usually  symmetrical,  and  the  irregular  atrophies  occurring 
during  the  later  fetal  period,  which  are  largely  due  to  intra-uterine 
compression. 

A  meningocele  or  encephalocele  at  the  root  of  the  nose  or  close  to 
the  outer  border  of  the  orbit  may  be  accompanied  by  defective  develop- 
ment of  the  nasal  or  malar  bones.  The  frontal  bone  itself  may  be 
defective,  as  in  a  case  recorded  by  Lannelogue  and  MenarcP  or  in  the 
patient  of  Samelson,^  who  at  23  years  of  age  showed  a  cavity,  due  to 

^  Trans.  Amer.  Surg'l  Ass'n,  1895. 

-  Affections  Cong^nitales,  i,  437. 

'  Mason,  Surgery  of  the  Face,  p.  109. 


62  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

the  deficiency  of  bone,  covered  by  thickened  integument  through 
which  the  cerebral  pulsation  was  visible.  Mason  mentions  a  case  of 
Delpech  in  which  there  was  a  congenital  absence  of  the  right  nasal 
and  lachrymal  bones,  the  nasal  process  of  the  upper  jaw  and  the  cor- 
responding soft  parts.  Maisonneuve  published  in  1855  the  report  of 
a  nine  months'  old  girl  who  showed  complete  absence  of  the  promi- 
nence of  the  nose.  The  cartilages  and  presumably  the  nasal  bones  were 
here  wanting.  The  surface  at  the  region  of  the  nose  was  perforated  by 
two  small  orifices.  The  countenance  is  said  to  have  been  grotesque. 
Maisonneuve  attempted  improvement  by  a  rhinoplastic  operation, 
but  the  outcome  is  not  known  to  me.  Mason  also  refers  to  Gay's  case 
of  absence  of  nasal  bones.  Lannelogue  and  Menard  report  a  similar 
instance  observed  at  the  Trousseau  Hospital.  I  once  saw  in  the 
practice  of  Dr.  L.  W.  Fox  a  child  with  congenital  absence  of  the  upper 
eyelids. 

When  there  exists  congenital  deformities  of  the  ears,  lips  and  other 
parts  of  the  face,  it  is  not  unusual  to  have  the  whole  side  of  the  face 
smaller  than  normal.  This  may  perhaps  be  remedied  by  ligation  of 
the  external  carotid  artery  on  the  larger  side  early  in  infancy,  in  order 
to  diminish  relatively  the  blood  supply  to  that  portion  of  the  face. 

When  the  temporo-maxillary  joint  becomes  ankylosecl  in  early 
childhood,  atrophy  of  the  lower  jaw  occurs,  because  its  functional 
activity  is  destroyed  by  the  pathological  change.  Some  of  the  so- 
called  congenital  dislocations  of  this  joint  are  really  cases  of  defective 
development  of  the  articulating  surfaces.  Congenital  bilateral 
atrophy  of  the  jaw  with  or  without  imperfect  mobility  also  occurs. 
The  facial  deformity,  due  to  the  want  of  prominence  in  the  chin,  is 
very  great  in  these  cases  of  mandibular  atrophy. 

Unilateral  atrophy  of  the  inferior  maxillary  bone  occurs,  and  has 
apparently  been  described  by  some  authors  under  the  name  of  congeni- 
tal dislocation.  I  recently  operated  to  make  almost  an  entire  ear  in  a 
condition  somewhat  like  this.  Roulland  describes  an  infant,  which 
with  other  anomalies  had  no  coronoid  process,  no  condyle  and  no 
articulating  surface  to  the  right  half  of  the  jaw  which  ended  posteriorly 
in  a  pointed  extremity.  The  left  half  of  the  bone  was  normal.  The 
right  malar  bone  was  also  atrophic  in  size. 

Facial  atrophy  due  to  compression  during  the  fetal  period  is 
often  accompanied  by  other  deformities  similarly  obtained  in  the 
amniotic  sac.  Torticollis,  curvature  of  the  trunk  and  bending  of  the 
limbs  are  seen;  but  the  head  is  especially  liable  to  show  these  pres- 
sure distortions. 


FISTULES,  FISSURES,  ENCEPHALOCELE  AND  ATROPHY         63 

Borel,  Buclin,  and  Lannelogue  and  Menard  have  reported^  interest- 
ing cases  of  this  character.  One  of  the  cases  recorded  by  the  last 
named  writers  was  fourteen  years  old  when  examined. 

Deformity  due  to  the  absence  of  the  normal  bony  framework  may 
be  relieved  in  some  instances  by  the  introduction  under  the  skin  of 
melted  paraffin,  which  subsequently  hardens.  The  paraffin  is  injected 
while  soft  by  means  of  a  hypodermic  syringe  and  may  be  moulded  with 
the  fingers  before  it  solidifies  in  the  tissues.  Bone  or  cartilage  grafts 
as  used  in  correcting  the  deformity  in  depressed  nasal  bridge  are 
the  best  materials  after  paraffin.  The  skin  is  dissected  up,  the  prop- 
erly carved  piece  or  graft  put  in  position,  and  the  wound  closed.  The 
shape  of  the  graft  is  determined  by  making  a  cast  of  the  nose  with 
plaster  of  Paris.  Healing  occurs  promptly  and  the  foreign  body 
remains  permanently  imbedded  in  the  tissues.  Keen  and  others  have 
used  metallic  plates  or  celluloid  in  the  same  way  to  correct  the  deform- 
ity of  "saddle-nose."  Grafts  of  bone  or  cartilage  are  obtained  from 
the  tibia  or  the  costal  cartilages. 

In  some  cases  the  deformity  from  deficient  bones  might  be  lessened 
perhaps  by  removing  bone  from  the  neighborhood,  in  order  to  lessen 
the  relative  disproportion  of  parts.  The  principle  is  the  same  as  that 
utilized  when  I  remove  a  V-shape  piece  from  the  middle  of  the  lower 
lip,  if  the  upper  lip  after  a  harelip  operation  is  exceedingly  tense. 
Osteoplastic  operations  and  the  wearing  of  external  prosthetic  ap- 
pliances of  wax,  papier-mache,  rubber,  metal  or  celluloid  may  be 
of  service  in  certain  cases. 

In  atrophy  of  the  lower  jaw  associated  with  defective  mobility  of 
the  temporo-maxillary  articulation,  osteotomy  or  some  operative 
procedure  to  permit  motion  must  be  done  as  soon  as  possible.  Use  of 
the  jaw  develops  the  bone  as  well  as  the  attached  muscles.  Restora- 
tion of  motion  will  often  induce  remarkable  increase  in  size  of  mandible. 
Lane,  Lilienthal  and  Babcock  have  reported  successful  operations 
for  ankylosis  and  for  malocclusion  of  teeth. 

Lagenbeck^  operated  successfully  on  a  case  of  this  kind  in  a  boy 
of  seventeen  years  who  was  born  with  an  imperfectly  developed  lower 
jaw,  whose  movements  had  become  more  and  more  restricted.  The 
operator  divided  the  masseters  and  then  made  a  section  through  the 
coronoid  processes.  As  the  boy  had  almost  passed  the  period  of 
youth  it  is  not  very  likely  that  much  change  in  facial  contour  occurred; 
though  alimentation  was  rendered  more  eas^^ 

One  side  of  the  face  of  a  child  ma}^  fail  to  grow  as  rapidh^  as  the 

^  Affections  Congenitales,  Lannelogue  and  Menard,  i,  499  and  508. 
^  Affections  Congenitales,  Lannelogue  and  Menard,  i,  421. 


64  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

other,  if  its  development  is  not  stimulated  by  a  normal  functional 
activity  of  the  organs  and  muscles  pertaining  to  it.  This  is  identical 
with  the  atrophy  mentioned  above  as  occurring  when  ankylosis  of  the 
lower  jaw  has  happened  in  early  life.  Such  one-sided  atrophy  of  the 
facial  bones  and  soft  parts  is  seen,  when  eyes  have  been  removed  or 
have  undergone  degenerative  changes,  and  when  congenital  or  trau- 
matic torticollis  has  prevented  proper  movement  and  exercise  of  the 
muscles  of  the  neck  and  face. 

The  trophoneurosis,  which  causes  facial  hemiatrophy,  not  only 
in  children,  but  also  in  adults  whose  features  have  gained  their  full 
growth,  deserves  mention  here,  though  it  is  a  condition  practically 
unamenable  to  treatment.  It  is  quite  different  from  the  want  of 
growth  just  mentioned.  Under  the  name  progressive  unilateral  facial 
atrophy"-  and  facial  hemiatrophy,  it  has  been  described  and  studied  by 
neurologists.  A  circumscribed  atrophy  begins,  on  one  side  of  the  face, 
in  the  skin,  which  becomes  thinned,  whitish,  and  parchment-like. 
The  process  gradually  extends  from  the  original  spot  and  slowly  in- 
vades surrounding  skin  and  the  subcutaneous  tissues.  The  atrophy 
may  involve  all  the  structures,  including  the  bones;  and  occasionally 
though  rarely  crosses  the  middle  line  of  the  face.  Muscular  twitching 
and  spasm  may  occur  and  neuralgia  is  not  uncommon.  After  a  time 
the  progress  of  the  nutritive  alteration  is  arrested  spontaneously, 
but  the  disfigurement  persists.  The  hollows  might  be  filled  with 
paraffin  perhaps  with  satisfaction. 

Local  injury  seems  to  be  the  most  frequent  cause;  and  Mobius  is 
inclined  to  believe  that  a  local  infection  occurs.  It  has  followed  burn 
of  the  cheek,  destruction  of  the  eye,  and  tonsillitis.  It  is  possible  that 
a  neuritis  of  the  trigeminal  nerve  is  the  immediate  cause.  The 
disease  appears  to  be  similar  in  its  nature  to  scleroderma  and  morphea. 

The  whitish  or  yellowish-white  pits  and  troughs  in  the  surface 
of  the  face  due  to  the  atrophy  of  the  skin  and  subcutaneous  fat  are 
characteristic  and  very  disfiguring.  The  face  sometimes  looks  as 
if  scarred  by  a  sabre  cut.  The  hair  of  the  eyelids,  brow,  beard  or 
head  may  become  gray  or  fall  out. 

Berend^  has  reported  a  case  where  the  atrophy  involved  the  left 
side  of  the  face  as  far  down  as  the  corner  of  the  mouth,  while  on  the 
right  side  the  disease  was  present  below  the  level  of  the  mouth.     It 

1  Pepper's  System  of  Medicine,  v.  693,  Article  by  C.  K.  Mills. 
Dercum's  Text  Book  of  Nervous  Diseases,  904,  Article  by  Joseph  Collins. 
Nothnagel's   Handbuch  der  Specielle  Pathologie  und  Therapie,  Article  by 
P.  J.  Mobius. 

2  Lancet,  Sept.  14,  1895,  p.  682. 


FISTULES,  FISSURES,  ENCEPHALOCELE  AND  ATROPHY         65 

seemed  as  if  the  first  and  second  divisions  of  the  left  trigeminus  and  the 
third  division  of  the  right  trigeminus  had  been  implicated  in  the 
disorder.  Williams  records^  the  case  of  a  negro  suffering  from  facial 
hemiatrophy,  whose  upper  maxilla  and  malar  bone  on  the  right  side 
were  scarcely  half  as  large  as  the  corresponding  bones  on  the  other 
side. 

Treatment    of    hemiatrophy    of   the    face  is    unavailing.     Mobius 
has  suggested  that  the  spot  originally  showing  atrophy  might  be  dis- 


FlG. 


25. — Unilateral  atrophy  of  face,  with  abscess  communicating  with  accessory  sinuses  of  nose 

{Author's  patient.) 


sected  out  in  the  effort  to  arrest  the  progress  of  the  disease.  The 
tonsillitis,  diseased  teeth,  or  other  condition  apparently  concerned  in 
the  origin  of  these  cases  should  receive  efficient  and  prompt  treatment. 
Stretching  or  neurectomy  of  the  trifacial  nerve  suggests  itself  as  of 
possible  value.  Extract  of  thyroid  gland  should  be  given  a  trial. 
It  is  fortunate  that  the  atrophic  process  seems  to  finally  halt  sponta- 
neously; but  the  disfigurement  is  usually  great  by  that  time,  and 
is  permanent. 

1  Jnl.  Nervous  and  Mental  Diseases,  xx  (1893),  838. 
5 


66 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Hypertrophy  of  the  Face. 

Unilateral  hypertrophy  of  the  face  is  more  common  than  unilat- 
eral facial  atrophy.  It  is  probably  a  tropho-neurosis,  due  to  an  irri- 
tative lesion  of  the  trophic  fibers  of  the  trifacial  nerve.  A  similar 
disease  causing  uniform  enlargement  of  the  bones  and  soft  parts  of 
the  whole  head  has  been  described  by  Starr^  under  the  name  megalo- 
cephalie.  It  is  probable  that  his  case  would  come  under  the  head 
of  osseous  leontiasis  of  Virchow;  though  it  somewhat  resembled 
acromegaly. 


Fig.  26. — Hypertrophy  of  skin 
and  subcutaneous  fascia.  {Author's 
patient.) 


Fig.  27. — Case  of  hypertrophy  of  skin  after 
incision,  skingraf  ting ,  and  brachial  flap  applied 
to  face.     Same  patient  as  preceding  figure. 


Unilateral  hypertrophy  of  the  face  is  exhibited  principally  by 
enlargement  of  the  zygoma,  eyebrow,  jaw,  and  cheek;  and  at  first 
sight  may  suggest  to  the  observer  hemifacial  atrophy  of  the  other  side. 
The  nutritive  disturbance,  which  is  slowly  progressive,  involves  the 
soft  parts  as  well  as  the  bone.  The  eyelids  and  ears  may  become  un- 
usually large  and  the  hair  coarser,  on  the  hypertrophied  side.  The 
facial  furrows  are  deepened  and  the  expression  changed.  The  skin 
is  sometimes  normal  in  color;  but  it  is  apparently  apt  to  be  rough, 
thick  and  dark.     The  muscles  are  said  to  be  atrophied. 

In  Montgomery's  case^  the  excision  of  large  pieces  of  skin  from 
the  malar  region,  upper  lip  and  chin  improved  the  patient's  appearance. 


^  American  Jnl.  Med.  Sciences,  Dec,  1894,  p.  675. 
2  Medical  News,  July  15,  1893,  p.  64. 


FISTULES,  FISSURES,  ENCEPHALOCELE  AND  ATROPHY         67 

Perhaps  extract  of  thyroid  gland  may  be  a  beneficial  remedy  in  this 
condition. 

Congenital  elephantiasis,  or  hypertrophy  of  the  skin  and  subcu- 
taneous tissue  of  the  face,  without  involvement  of  the  bone  is  occasion- 
ally observed.  It  is  a  sort  of  dermatolysis  and  causes  great  facial 
disfigurement.  Bull  has  reported^  an  instance  in  a  young  man,  the 
side  of  whose  face  resembled  that  of  a  dog.  The  disease  was  one  of 
the  forms  of  fibroma  molluscum.  Marked  improvement  was  obtained 
by  two  operations  by  which  the  redundant  tissue  was  excised. 

In  the  first  operation  the  redundant  and  thickened  upper  eyelid, 
which  hung  down  over  the  ocular  region  in  a  large  flap,  was  removed. 
When  the  second  operation  was  performed  an  ellipitical  incision  was 


Fig.  28. — Hyperostosis  of  upper  and  lower  jaws.     {Patient  of  author.) 

made  from  the  angle  of  the  mouth  nearly  to  the  ear.  This  cut  was 
carried  entirely  through  the  cheek  to  the  oral  cavity  and  removed  a 
piece  of  hypertrophied  tissue  three  inches  wide  at  the  point  of  great- 
est breadth.  The  mucous  membrane  was  sutured  with  catgut;  the 
skin  with  silk.  I  operated  upon  a  similar  case  some  years  ago  and 
greatly  improved  the  man's  appearance  by  a  series  of  operations. 

Occasionally  bony  masses  form  in  connection  with  the  bones  of  the 
face  causing  great  disfigurement.  The  upper  and  lower  jaws  seem  to 
be  particularly  affected  in  this  rather  rare  condition,  to  which  the 
terms  leontiasis  ossea  and  hyperostosis  of  the  facial  bones  have  been 
applied.  It  is  said  by  Sutton  to  be  a  modification  of  rickets.  The 
accompanying  illustration  is  taken  from  the  photograph  of  a  patient 
under  my  care  some  years  ago.  There  are  sj'^mmetrical  bony  masses 
running  downward  and  outward  from  the  bridge  of  the  nose  on  each 
side;  and  a  large  rounded  prominence  of  bone  on  the  front  and  lower 

1  N.  y.  Med.  Jnl,  June  20,  1891. 


68  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

border  of  the  lower  jaw  on  each  side.  The  nose  is  almost  totally 
occluded  by  encroachment  of  the  masses  growing  from  the  upper 
maxillae.^  I  advocated  removal  of  these  masses  with  the  chisel,  but 
the  patient  never  consented  to  have  me  operate.  The  incision  for  the 
removal  of  the  lower  masses  would  have  been  made  under  the  lower 
jaw  so  that  the  scar  would  have  been  out  of  sight  as  much  as  possible. 
The  upper  osteomas  would  have  been  attacked  through  cuts  made  in 
the  direction  of  the  naso-labial  furrow  which  in  this  case  was  practi- 
cally absent  because  of  the  bony  ridge. 

Horsley  has  operated  on  such  cases^  and  says  it  is  easy  to  distin- 
guish the  new  bone  from  the  original  by  its  abnormal  vascularity. 

J.  Bland  Sutton  gives^  a  cut  of  a  case  of  symmetrical  exostoses  of 
the  nasal  processes  of  the  upper  maxillae,  which  could  probably  have 
been  readily  removed  by  chiseling,  and  the  deformity  greatly  relieved. 
To  do  such  operations  neatly  requires  small  and  sharp  chisels  and 
gouges.  The  surface  should  be  made  quite  smooth,  after  the  bony 
tumor  has  been  cut  away,  before.the  wound  in  the  skin  is  closed. 

Dennis'  Surgery*  gives  a  cut  of  a  skull  showing  an  extraordinary 
degree  of  deformity  from  osseous  leontiasis.         > 

1  Annals  of  Surgery,  March,  1896,  p.  303. 

^  Practitioner,  July,  1895.  ' 

3  Tumors,  p.  27,  Fig.  16. 

*  Vol.  ii,  p.  224. 


CHAPTER  VII. 

DISFIGURING  SKIN  DISEASES  REQUIRING  SURGICAL   TREAT- 
MENT. 

Comedo. 

Inspissated  secretion  of  a  sebaceous  gland  may  by  being  retained 
in  the  duct,  become  conspicuous  as  a  yellowish- white  or  brownish  spot 
upon  the  skin.  The  little  mass  of  secretion,  called  comedo  by  the 
dermatologist,  a  ''blackhead"  or  ''skin  worm"  by  the  unscientific,  is 
unsightly.     Some  patients  may  have  many  of  them  upon  the  face. 

The  little  cylindrical  masses  of  hardened  fat  and  epithelium  can  be 
pressed  out  of  the  ducts,  and  look  not  unlike  a  small  worm.  They  can 
sometimes  be  squeezed  out  by  the  fingers;  but  an  instrument  shaped 
like  a  watch  key  or  an  extractor  made  for  the  purpose  are  much  more 
efficacious.  The  latter  permits  the  operation  to  be  done  with  little 
pain.  The  watch  key  method  consists  in  placing  the  opening  of  the 
instrument  over  the  orifice  of  the  duct  and  pressing  upon  the  skin  so  as 
to  extrude  the  plug  of  secretion  into  the  hollow  of  the  key.  The 
extractor  of  Piffard  has  a  bowl-shaped  end  with  an  aperture  in  it.  A 
needle  held  in  a  holder  or  mounted  on  a  handle  may  often  be  advan- 
tageously employed. 

The  little  operation  is  made  less  troublesome  to  the  surgeon  if  the 
skin  has  been  previously  moistened  with  glycerine  solution.  After 
removal  of  the  comedones  the  skin  is  to  be  sponged  with  hot  water  and 
soap,  thoroughly  dried  and  then  treated  with  sulphur  ointment  or 
some  similar  preparation.  Any  defect  in  the  general  health  of  the 
patient  should  be  given  attention.  The  digestive  organs  in  this  con- 
dition as  in  acne  are  often  at  fault.  Occasional  applications  of  ether 
to  the  skin  to  dissolve  the  fat  in  the  ducts  ma}^  be  valuable. 

Milium. 

These  little,  yellowish  or  whitish,  hard,  non-inflammatory  eleva- 
tions in  the  skin  are  to  be  treated  bj'-  dividing  the  epidermis  with 
knife  or  scissors  and  turning  out  the  dry,  pearly  mass  of  secretion. 
Galvanism  may  be  effectively  emploj^ed  by  introducing  the  point  of  a 
needle  attached  to  the  negative  pole  in  the  milium,  while  a  wet  sponge 
at  the  positive  pole  is  applied  to  the  neighboring  skin. 

69 


70  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

MoUuscum  Verrucosum. 

This  condition,  also  called  molluscum  sebaceum  and  molluscum 
epitheliale,  consists  in  the  formation  in  the  skin  of  small,  firm  tumors, 
about  the  size  of  a  pea,  of  a  waxy  white  or  pinkish  color,  looking  very 
much  like  a  small  mother-of-pearl  shirt-button  and  containing  caseous 
matter  and  small  pod-like  bodies.  They  sometimes  assume  a  warty 
or  horny  aspect;  at  other  times  they  inflame  and  may  ulcerate  or 
suppurate.  These  sebaceous  growths  are  most  common  in  children 
and  may  drop  off  spontaneously.  The  removal  of  the  little  tumors 
may  be  accomplished  by  electrolysis  after  squeezing  out  the  contents, 
or  by  the  use  of  the  ligature,  knife,  or  curette.  Applying  liquefied  but 
undiluted  carbolic  acid  to  the  lesions  and  then  painting  a  little  flexible 
collodion  upon  them  is  recommended.  An  ointment  of  sulphur  5j> 
creosote  mxx,  ointment  5j>  is  said  to  be  useful.  No  special  scar  is 
left  by  excision  unless  the  molluscum  be  a  larger  one  than  the  average. 
That  they  disappear  spontaneously  must  not  be  forgotten. 

Sebaceous  Cyst  or  Atheroma. 

The  treatment  of  sebaceous  cyst  is  to  remove  the  sac  with  its 
contained  sebaceous  like  material.  The  quickest  method  is  to  split 
the  tumor  in  half  with  a  narrow  bistoury  thrust  through  its  base,  with  the 
cutting  edge  upward ;  and  then  to  seize  the  cyst  wall  with  a  pair  of  forceps 
and  drag  it  and  its  contents  out  through  the  wound  in  the  skin.  The 
cyst  is  easily  enucleated  in  this  manner,  or  by  being  dug  out  of  its 
bed  with  the  handle  of  the  knife  after  the  incision  has  been  made. 
If  the  surgeon  prefers,  he  may  incise  the  skin  and  dissect  out  the  sac 
without  cutting  its  wall.  Unless  attacks  of  inflammation,  which  are  not 
common,  have  caused  abnormal  adhesions  between  the  sac  wall  and 
the  surrounding  tissues,  the  enucleation  is  easy.  The  wound  is  then 
to  be  closed  with  sutures,  and  dressed  with  one  or  two  strips  of  gauze 
saturated  with  collodion. 

Care  should  be  taken  to  make  the  incisions  in  the  direction  of  the 
cutaneous  furrows,  so  as  to  prevent  disfigurement  from  conspicuous 
scars. 

Acne  and  Acne  Rosacea. 

The  inflammatory  affection  of  the  sebaceous  glands,  called  sim- 
ple acne,  and  the  chronic  congestion  of  the  skin  resulting  in  inflamma- 
tion of  these  glands  and  a  production  of  connective  tissue,  which  is 
termed    acne    rosacea,   sometimes  requires  mild  surgical  treatment. 


SKIN  DISEASES  REQUIRING  SURGICAL  TREATMENT  71 

Regulation  of  the  digestion  and  correction  of  menstrual  or  other 
irregularities  must  be  obtained;  and  the  skin  should  be  stimulated  by 
applications  of  sulphur  or  similar  remedies.  Active  friction  with  hot 
water  and  soap  applied  by  means  of  a  nail  brush  may  be  beneficial. 
In  severe  cases  of  acne,  however,  a  curette  should  be  freely  employed 
to  scrape  off  the  top  of  the  papules  and  pustules.  This  leads  to  the 
escape  of  the  sebaceous  material  and  pus,  and  stimulates  the  skin  so 
that  the  inflammatory  exudate  is  absorbed.  When  such  severe  treat- 
ment does  not  seem  demanded  the  separate  papules  may  be  punct- 
ured or  incised  with  a  small  knife  or  cataract  needle.     The  bleeding 


Fig.  29. — Nasal  deformity  from  acne  rosacea      (Tillmanns.) 

mduced  by  these  measures  should  be  encouraged  by  bathing  the  face 
in  hot  water.  This  surgical  treatment  may  be  repeated  twice  a  week 
with  satisfactory  results.  When  deeply  seated  nodules  exist  they 
may  be  quite  freely  incised,  the  contents  extracted  and  the  cavities 
touched  with  undiluted  carbolic  acid. 

The  dilated  vessels,  causing  the  reddish  or  purplish  skin  seen 
in  rosaceous  acne,  can  be  destroyed  by  puncture  with  the  electrolytic 
needle;  and  small  nodular  masses  even  may  be  successfully  treated  by 
repeated  punctures.  Larger  masses  of  hypertrophied  skin  due  to 
this  chronic  disease  are  best  managed  by  excision.  The  nose  though 
greatly  deformed  may  be  pared  into  satisfactory  shape  by  the  free 
use  of  the  knife. 

Lentigo,  Chloasma,  and  Tattooing. 

Freckles,  ''liver-spots"  and  similar  pigmentary  deposits  in  the 
skin  are  treated  locally  by  inducing  the  production  of  new  epidermis 
free  from  abnormal  pigment  in  place  of  the  old  pigmented  epithelium. 
Vigorous  blistering  will  remove  the  old  epidermis,  out  is  to  be  avoided 
because  it  is  followed  by  greater  discoloration.  Milder  measures 
are  therefore  to  be  employed.     Lotions  containing  mercuric  chloride 


72  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

are  very  popular.  The  following  is  recommended  by  van  Harlingen: 
corrosive  chloride  of  mercury  gr.  vss.,  zinc  sulphate  5ss,  lead  sub- 
acetate  oiss,  distilled  water  f  §iv.  This  lotion  is  to  be  applied  morn- 
ing and  evening.  Electrolysis  has  been  advocated.  A  minute  drop 
of  undiluted  carbolic  acid  is  said  to  be  effectual  in  causing  freckles  to 
disappear.     It  may  not  cause  a  permanent  cure. 

Hyde  believes  that  the  local  treatment  of  these  pigmentations 
is  unsatisfactory.  The  most  rapidly  effective  methods  are  as  a  rule 
followed  by  the  occurrence  of  greater  discolorations;  and  even  the 
less  rapidly  acting  applications  are  in  his  opinion  likely  to  lead  to  a 
final  though  less  readily  recognized  exaggeration  of  the  disfigurement. 
He  thinks  that  general  treatment  of  the  fundamental  cause  is  the 
rational  method. 

The  removal  of  tattoo  marks  has  been  discussed  in  an  early  sec- 
tion of  this  work  under  Wounds  of  the  Face. 

Leucoderma,  Vitiligo,  and  Smooth  Scars. 

Localized  absence  of  pigment  in  the  skin  causing  whitish  patches, 
whether  congenital  (leucoderma)  or  acquired  (vitiligo),  is  not  very 
amenable  to  treatment.  Hypodermic  administration  of  pilocarpin 
has  had  advocates.  Sometimes  the  condition  can  be  made  less  con- 
spicuous by  removing  the  excess  of  pigment  apt  to  exist  around  the 
border  of  the  atrophic  white  patch.  This  may  be  attempted  by  the 
means   employed  in  removing  freckles   and   similar  pigmentations. 

Coloring  the  white  patches  by  tattooing  has  been  mentioned,  but 
has  not  given  brilliant  results.  Paschkis  thinks  this  due  to  want  of 
careful  experimentation  in  obtaining  proper  coloring  material.  He 
says  that  the  brilliant  red  of  the  lips  can  be  imitated  by  tattooing  with 
cinnabar.  Baryta  white  with  a  judicious  mixture  of  reds  and  browns 
has  been  advised  by  the  same  author. 

Extensive  scars  may  cause  disfigurement  by  the  absence  of  pig- 
ment in  the  cicatricial  skin,  even  when  the  scar  tissue  is  smooth, 
soft  and  flexible.  Nodular  and  contracted  scar  tissue  in  some  situa- 
tions may  be  excised  and  a  linear  scar  substituted  for  the  irregularly 
distorted  skin.  When  the  scar,  however,  is  smooth,  soft  and  flexible 
tattooing  is  the  only  measure  to  be  considered.  It  is  possible  that 
in  the  future  combinations  of  pigments  satisfactory  for  this  purpose 
may  be  discovered. 

Warts,  Horns  and  Moles. 

In  old  people  there  are  sometimes  seen  on  the  face  patches  of 
yellowish-brown  or  black  epidermic  scales,   slightly  elevated  above 


SKIN  DISEASES  REQUIRIXG  SURGICAL  TREATMENT 


73 


the  normal  surface.  These  plates  of  epidermis  may  be  removed  by 
inunctions  of  oil  and  the  reddish  surface  beneath  kept  dressed  with 
salicylic  acid  and  sulphur  prepared  as  an  ointment.  A  good  formula 
is  said  to  be  salicjdic  acid  gr.  xxx,  sulphur  5ss,  starch  §ss,  ointment 
of  rose  water  §j.  If  there  is  any  suspicion  of  epitheliomatous  degener- 
ation occurring  in  the  patches,  the  abnormal  area  should  be  excised, 
or  treated  with  caustics  or  the  IL-rsiy. 

The  condition  just  mentioned  is  sometimes  called  senile  wart, 
but  the  term  senile  keratosis  is  better. 

The  warts  of  various  forms  which  occur  quite  frequently  on  the 
face  can  be  removed  by  puncture  with  the  electrolytic  needle.  The 
growth  need  not  be  completely  destroyed  by  electrolysis,  for  quite 


Fig.  30. — Serpentine  papilloma  of  mouth,  chin  and  neck.     {Churchill.) 


often  a  single  puncture  will  cause  the  little  tumor  to  slowly  disappear 
by  absorptive  processes.  Pedunculated  warts  may  be  removed  by 
ligation  of  the  pedicle;  sessile  ones  by  strangulation  after  trans- 
fixion of  the  base  with  fine  ''insect  pins."  Caustic  applications 
are  often  preferred  by  the  patient.  Then  chromic  acid,  or  liquor 
formaldehydi  may  be  used.  These  active  caustics  should  be 
cautiously  applied,  hj  means  of  a  glass  rod  or  small  piece  of  stick. 
The  rod  is  dipped  into  the  cauterizing  fluid  and  a  portion  of  a  drop 
applied  to  the  surface  of  the  wart.  A  few  days  later  the  devitalized 
tissue  is  cut  away  from  the  surface  of  the  wart  with  a  sharp  knife. 


74  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

and  the  caustic  applied  again.  This  process  is  repeated  about  twice 
a  week  until  the  growth  is  removed.  Salicylic  acid,  5j;  collodion  §j 
makes  a  good  caustic  application.  It  is  to  be  repeatedly  applied. 
The  X-ray  may  be  used  in  the  treatment  of  these  lesions. 

Erasion  or  excision  of  a  wart  may  be  the  most  satisfactory  treat- 
ment if  the  patient  objects  to  the  slowness  of  the  cauterization.  This 
is  probably  better  than  destroying  the  tumors  with  the  galvano- 
cautery  as  the  scar  may  in  most  instances  perhaps  be  made  less  con- 
spicuous. 

In  old  persons  warts  should  always  be  removed  thoroughly  as 
epithelioma  is  not  a  rare  sequence.  Repeated  cauterization  in  many 
such  cases  is  less  efficient  and  more  painful  than  prompt  and  radical 
removal  with  the  knife.  Some  evidence  exists  which  seems  to  show 
that  the  irritation  of  prolonged  cauterization  may  be  the  cause  of 
malignant  degeneration.  Care  must  be  taken  to  avoid  deformity  by 
secondary  cicatricial  dragging  of  the  eyelids  or  mouth.  Plastic 
procedures  are  often  necessary  to  avoid  this  mishap.  I  usually  do 
the  plastic  operation,  and  thus  transfer  cicatricial  contraction  to  an 
unimportant  part  of  the  face  at  the  time  of  the  excision  of  the  growth. 
The  use  of  the  X-ray  has  been  found  very  satisfactory  in  the  removal 
of  warts  and  superficial  epithelial  cancers. 

Horny  growths  are  found  upon  the  forehead,  eyelid  and  lip.  They 
may  increase  till  several  inches  long  and  become  twisted  as  they  grow. 
They  are  usually  of  a  dark  color.  These  cutaneous  horns  on  the  face 
cause  great  disfigurement,  but  are  fortunately  rare.  They  often  start 
from  warts,  scars  and  sebaceous  cysts  and  consist  of  layers  of  hyper- 
trophied  epithelium. 

The  treatment  consists  in  excision.  A  considerable  border  of 
skin  around  the  base  of  the  horn  should  be  cut  away  and  the  parts 
brought  together  by  suture  so  as  to  make  as  insignificant  a  scar  as  is 
practicable.     The  dissection  should  go  down  to  the  superficial  fascia. 

Cauterization  of  the  raw  surface  after  the  horn  has  been  torn 
from  its  attachment  has  been  recommended.  This  may  prevent  re- 
production of  the  horny  tumor,  but  would  probably  cause  greater 
scarring  than  is  desirable  or  necessary.  Excision  alone  will  often  be 
preferable.  If  caustics  are  employed  they  must  be  very  active. 
Chloride  of  zinc  would  be  efficient  in  solution  or  as  a  paste.  The  actual 
cautery  has  been  recommended. 

Moles  may  consist  only  of  abnormally  great  pigmentation  of  a 
limited  area  of  the  skin,  or  they  may  in  addition  be  elevated  above 
the  skin  and  have  a  rough  and  warty,  or  a  hairy  surface.  They  are 
usually  rather  small,  but  may  cover  a  large  part  of  the  face  and  neck. 


SKIN  DISEASES  REQUIRING  SURGICAL  TREATMENT  75 

The  yellow-brown  or  black  hue  makes  them  very  conspicuous  and 
annoying. 

Small  moles  are  successfully  treated  by  strangulation  after  trans- 
fixion with  insect  pins,  by  caustics,  or  excision. 

Electrolysis  is  also  a  good  method  of  deahng  with  them.  It  is 
said  that  the  needle  should  be  thrust  no  deeper  than  the  epidermis. 
Hardaway  says  that  he  has  removed  by  electrolysis  a  warty  mole 
nearly  two  inches  in  diameter  leaving  scarcely  any  scar.  He  advo- 
cates removing  the  hairs  first  by  electrolytic  means  before  attacking 
the  mole  itself. 

Large  moles  are  to  be  treated  by  excision  if  the  scarring  will  be  of 
no  consequence.  If  the  scar  will  be  more  deforming  than  the  mole  it 
has  been  the  custom  to  refrain  from  interference. 

Ricketts  has  recommended  that  such  moles,  whether  elevated 
or  non-elevated,  brown  or  red,  be  excised  and  the  raw  surface  covered 
with  shavings  of  skin  taken  from  some  other  part  of  the  patient,  after 
the  manner  of  Thiersch.  All  surgeons  know  the  value  of  this  method 
of  skin  grafting.  By  it  a  white  scar  is  substituted  for  the  pigmented 
tissue.  The  whiteness  of  the  scar  is  a  less  conspicuous  disfigurement 
than  the  previous  pigmented  surface,  unless  the  cicatrix  causes  dis- 
tortion by  contraction.  The  skin  grafting  probably  lessens  the  tend- 
ency to  contraction.  Ricketts  recommends  that  the  shavings  of  skin 
be  made  as  large  as  possible.  I  have  never  tried  this  method  of  treat- 
ing moles,  but  believe  it  a  valuable  suggestion.  My  experience  in  cov- 
ering raw  surfaces,  made  for  other  reasons  on  the  face  and  elsewhere, 
by  skin  shavings  has  been  very  satisfactory.  Large  whole  thickness 
skin  grafts  may  also  be  used  after  excision  of  the  mole. 

The  mole  and  surrounding  skin  must  be  made  aseptic  and  the 
excision  done  aseptically.  Then  hemorrhage  is  arrested,  and  shav- 
ings cut  with  a  sharp  razor  from  the  thigh,  arm  or  abdomen.  The 
region  selected  to  furnish  the  grafts  must  be  sterilized  and  have  any 
previously  used  antiseptic  solution  removed  by  bathing  with  a  sterile 
normal  salt  solution.  The  razor  and  the  grafts  are  moistened  only 
with  normal  salt  solution,  previously  sterilized  by  heat.  The  skin  is 
then  made  taut  and  the  wet  razor  drawn  along  it  so  as  to  cut  a  very 
thin  shaving  of  skin.  The  upper  layers  of  the  skin  only  are  removed, 
there  is  Httle  bleeding  and  not  a  very  great  deal  of  pain.  A  number 
of  shavings  are  then  laid  upon  the  raw  surface  with  their  edges  over- 
lapping till  the  whole  wound  is  covered.  Over  these  rubber  tissue,  or 
better,  a  veil  of  gauze  or  a  net  coated  with  rubber  is  laid.  A  sterile 
gauze  dressing  is  then  applied  and  allow^ed  to  remain  undisturbed  for 
several  days. 


76 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Ether  may  be  given  if  the  operation  promises  to  be  a  long  one. 
Cocaine  injections  locally  would  relieve  the  pain,  but  would  possibly 
imperil  the  success  of  the  grafting  if  used  where  the  mole  was  excised 
or  where  the  grafts  were  cut.  Injections  into  the  nerve  supply  would 
be  free  from  this  objection. 

Nevus  Vasculosus,  Angioma,  Mother's  Mark.     Port  Wine  Mark. 

The  tumors  and  discolorations  of  the  skin  due  to  dilated  capillaries, 
veins  and  arteries  disfigure  by  their  color,  by  their  bulk  or  by  both. 
The  indication  is  to  destroy  the  abnormal  vessels  by  causing  oblitera- 
tion of  their  caliber,  to  extirpate  the  skin  and  subcutaneous  tissue 
involved  in  the  disease,  by  means  of  the  knife,  or  to  cause  necrosis  by 
ligation,  caustics  or  the  injection  of  boiling  water. 


Fig.  31. 

Fig.  31. — Congenital  angioma  of  tip  of  nose. 
Fig.  32. — The  same  case.     (Lateral  view.) 


Fig.  32. 
(Anterior  view.)      {Patient  of  Dr.  A.  R.  Craig.) 


The  former  indication  is  fulfilled  by  setting  up  an  inflammatory 
process  by  electrolysis,  which  is  useful  in  superficial  forms  of  the  disease. 
A  needle  attached  to  the  negative  pole  of  a  ten  or  twenty  cell  battery 
is  thrust  into  the  nevus  deeply  enough  to  reach  its  lower  surface,  and  the 
circuit  closed  by  applying  a  wet  sponge,  attached  to  the  positive  pole, 
on  the  skin  at  a  little  distance  from  the  site  of  operation.  It  is  rec- 
ommended to  attack  first  any  specially  prominent  vessel  that  may 
be  seen  in  the  skin.  When  the  tissues  grow  whitish  around  the  needle, 
the  sponge  is  raised  from  the  surface  and  the  needle  withdrawn. 
This  operation  is  repeated  a  number  of  times  in  one  portion  of  the  dis- 
colored skin.  As  a  result  inflammation  occurs,  which  subsides  in  a 
week  or  ten  days.  Then  another  portion  of  the  nevus  is  treated  in  a 
similar  way. 

Electrolysis  so  employed  is  painful,  but  local  or  general  anesthesia 


SKIN  DISEASES  REQUIRING  SURGICAL  TREATMENT  77 

will  obviate  this  objection.  Some  authorities  object  to  the  tediousness 
of  electrolysis  in  extensive  nevoid  discolorations  and  its  occasional 
production  of  suppuration,  sloughing  and  scarring.  Others  advocate 
it  strongly.  It  does  not  seem  available  in  angiomas  which  cause  a 
tumor. 

Multiple  puncture  with  fine  needles  moistened  with  a  25  to  30  per 
cent,  solution  of  chromic  acid  has  been  successfully  used;  and  alcohol 
has  been  injected  into  the  vascular  tissue  b}''  a  hypodermic  syringe. 
Squire  scarified  the  surface  with  a  special  instrument,  I  think,  making 
numerous  closely  placed  parallel  incisions,  and  crossing  these  at  a 
right  angle  with  similar  incisions.  The  cuts  are  made  obliquely  to 
the  surface  and  great  care  is  taken  not  to  displace  the  edges  of  the 
minute  wounds,  since  absence  of  visible  scarring  depends  upon  the 
accurate  approximation  of  the  edges.  This  method  has  not  met  with 
general  success. 

Very  small  nevi  are  readily  removed  by  caustics  and  the  white 
scar  is  inconsjjicuous.  Larger  ones  are  best  treated  by  excision,  which 
leaves  a  linear  scar;  this  is  often  unnoticed  if  it  corresponds  with  the 
wrinkles  of  the  region  of  the  face  in  which  it  is  situated.  Good  caustics 
are  chromic  acid,  nitric  acid,  zinc  chloride,  acid  nitrate  of  mercury, 
sodium  ethylate,  formaldehyde  and  mercuric  chloride.  Before  apply- 
ing caustics  the  skin  should  be  sterilized  and  the  eschar  due  to  the 
caustic  should  not  be  picked  off.  If  it  is  removed,  the  underlying 
ulcer  ma}'  become  infected  with  pyogenic  germs.  The  resulting 
suppuration  is  likely  to  result  in  more  scarring  than  would  occur 
if  the  devitalized  tissue  were  allowed  to  drop  off  spontaneously  after 
the  living  tissues  had  cicatrized  under  the  crust.  Then  the  caustic 
is  to  be  reapplied  if  necessary.  A  smooth  and  suiDerficial  scar  is  more 
apt  to  be  obtained  if  the  parts  are  kept  free  from  infection. 

The  red  hot  iron  would  probably  be  a  good  remedy  when  the 
mother's  mark  is  not  too  large.  Sterilization  should  be  obtained  be- 
fore the  actual  cautery  is  applied  and  should  be  maintained  by  an  efficient 
gauze  dressing  such  as  is  used  in  other  surgical  operations  until  the 
eschar  is  detached  spontaneously.     This  may  require  several  weeks. 

Care  must  be  taken  to  protect  the  surrounding  skin  from  scorching. 
This  may  be  done  by  using  a  small  cautery  iron;  or  by  protecting  the 
surrounding  surface  by  a  sheet  of  asbestos  or  other  poor  conductor 
of  heat  while  using  the  cautery. 

In  punctiform  nevi  acupuncture  with  a  red  hot  needle  may  be  all 
that  is  necessarv;  or  the  points  of  a  galvano-cautery  knife  ma}^  be 
momentaril}^  touched  to  the  discolored  skin. 

Strangulation  by  means  of  a  silk  or  catgut  ligature  tied  around  the 


78 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


base  of  the  tumor,  which  then  sloughs  is  not  infrequently  adopted 
for  the  removal  of  angiomatous  growths.  Unless  the  nevus  is  pedun- 
culated, and  it  very  frequently  is  not,  it  is  necessary  to  first  thrust 
under  the  tumor  a  slender  steel  pin  or  two  pins  at  right  angles.  The 
ligature  is  then  carried  around  the  growth  behind  the  pins  and  tightly 
tied.  The  tumor  becomes  engorged  with  blood.  I  usually  cut  away 
part  of  the  tumor  after  it  has  been  strangulated,  leaving  only  a  suffi- 
cient stump  to  hold  the  pins  and  ligature.  I  then  frequently  sear 
the  raw  surface  of  the  stump  with  undiluted  carbolic  acid. 

The  parts,  which  should  be  rendered  aseptic  before  this  operation  is 
begun,  should  be  kept  so  by  painting  the  wounds  made  by  the  pins 
with  the  undiluted  carbolic  acid  applied  to  the  stump.     The  pins  may 


Fig.  33. — Subcutaneous  angioma  of  check.     Excised  after  raising  flap.     Much  improvement. 

(Author's  patient.) 


be  removed  in  three  or  four  days.  If  suppuration  occurs  about  the 
punctures  scarring  is  apt  to  be  undesirably  conspicuous.  In  some 
instances  an  antiseptic  gauze  dressing  will  give  better  results. 
Wyeth's  suggestion  to  inject  boiling  water  into  the  tumor  by  means 
of  a  hypodermic  syringe  is  very  valuable.  The  syringe  is  filled  with 
boiling  water,  which  is  kept  boiling  by  holding  an  alcohol  lamp 
under  it.  A  few  drops  are  then  slowly  injected  into  the  spongy 
tumor  at  several  points.  This  is  repeated  every  few  days  until  the 
tumor  shrinks  and  disappears. 

If  the  angioma  is  other  than  very  small,  the  most  efficient  and 
least  disfiguring  treatment  is  to  excise  it,  as  any  other  tumor  with 
careful  consideration  as  to  the  direction  of  the  lines  of  incision.  These 
should  be  so  placed  as  to  leave  inconspicuous  scars.     Large  subcuta- 


SKIN  DISEASES  REQUIRING  SURGICAL  TREATMENT  79 

neous  angiomas  require  treatment  by  excision;  those  of  moderate  size, 
and  even  small  ones  are  often  best  treated  in  that  manner.  The 
knife  must  be  carried  through  tissues  free  from  the  abnormally  dilated 
vessels,  to  avoid  undue  hemorrhage  and  to  prevent  recurrence.  If  a 
small  portion  of  the  vascular  tumor  is  left  a  new  nevoid  tumor  will 
probably  develop  from  the  remains  of  the  old  one.  Angiomas  some- 
times require  repeated  operative  attacks  to  get  rid  of  the  entire  mass  of 
dilated  and  dilating  blood-vessels.  If  the  tumor  is  in  the  vessels  of 
the  subcutaneous  tissue  alone,  a  flap  of  skin  may  be  reflected  to  gain 
access  to  the  angioma.     After  the  excision  the  flap  is  replaced. 

When  the  size  or  situation  of  the  growth  makes  it  apparent  that 
the  excision  will  be  a  bloody  operation,  the  region  can  be  made  tempo- 
rarily anemic  by  carrying  with  a  long  needle  deep  ligatures  through  the 
skin  and  tying  the  tissues  in  mass.  Several  such  ligatures  placed 
around  the  operative  field  make  the  excision  free  from  risk  of  severe 
bleeding.  They  are  to  be  removed  after  the  abnormal  structure  has 
been  cut  out.  The  carotid  arteries  may  be  temporarily  clamped  in 
cases  where  fatal  bleeding  is  feared,  or  the  blood  may  be  imprisoned 
in  the  legs  or  arms  as  recommended  by  Dawbarn.  Hemostasis  is 
then  obtained  by  the  usual  methods. 

Skin  grafting  or  the  use  of  plastic  flaps  may  be  brought  into  re- 
quisition to  hide  deformity,  if  these  operations  have  been  extensive. 

Dermatolysis  and  Elephantiasis. 

The  circumscribed  hypertrophy  of  the  skin,  called  dermatolysis, 
in  which  soft  masses  of  loose  integument  hang  like  the  folds  of  a  gar- 
ment, occurs  in  the  facial  region.  The  masses  should  be  excised  by 
incisions  which  will  leave  scars  corresponding  with  the  normal 
wrinkles,  or  be  hidden  by  the  shadows  of  the  face.  These  conditions 
have  been  discussed  in  the  preceding  chapter. 

Lymphatic  obstruction  causing  elephantiasis,  whether  secondary 
to  repeated  inflammation  or  due  to  other  causes,  is  occasionally  ob- 
served in  the  face.  The  swollen,  discolored  and  indurated  integument 
will  require  operative  removal  with  the  knife  if  the  disfigurement  is  to 
be  climininshed.  The  character  and  extent  of  the  incisions  will  depend 
on  the  situation  of  the  lesion. 

Lymphangioma. 

Tumors  produced  by  dilatation  or  hypertrophy  of  the  lymph  ves- 
sels require  excision  or  other  operative  methods  identical  with  those 
used  in  treating  venous  and  arterial  angiomas. 


80  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

Scleroderma. 

This  induration,  rigidity  and  subsequent  atrophy  of  the  skin  is 
at  times  a  source  of  facial  deformity.  The  circumscribed  form  of 
scleroderma,  often  called  morphea  or  Addison's  keloid,  causes  firm 
and  smooth  patches  or  lines  of  altered  integument  surrounded  by  a 
violet  tinted  halo.  The  patches  may  be  elevated  above  the  surround- 
ing surface,  though  they  are  at  times  depressed.  In  the  late  stages 
an  atrophy  of  the  integument  occurs.  The  color  of  the  diseased  patch 
is  waxy  white,  grayish,  or  yellowish. 

Diffuse  scleroderma  of  the  face  gives  rise  to  an  expressionless, 
rigid  countenance.  The  atrophy  occurring  secondarily  may  be  very 
disfiguring.  Hemiatrophy  of  the  face  is,  at  least  in  some  cases, 
probably  the  secondary  result  of  scleroderma. 

Circumscribed  scleroderma  may  cause  atrophic  lines,  forming 
furrows  or  ridges  with  furrows  at  the  side.  Such  furrows  on  the  face 
are  disfiguring.  Sometimes  pigmentation  occurs  in  scleroderma; 
and  whitish  patches  also  may  be  associated  with  the  sclerosed  and 
pigmented  skin.  The  progress  of  the  thickening  and  atrophy  may  be 
very  chronic;  or  in  a  few  days  the  disease  may  make  notable  deformity 
from  the  sclerosed  and  subsequent  contraction  of  the  cutaneous 
structures. 

Extract  of  thyroid  gland  may  be  valuable  as  a  remedy  in  this 
disease.  If  the  patches  of  scleroma  are  small,  excision  is  advisable 
to  relieve  the  deformity. 

Rhinoscleroma. 

This  rare  granulomatous  affection  of  the  columella  and  also  of  the 
nose  causes  deformity  by  involving  these  structures  in  a  nodular  ma^ 
of  ivory-like  hardness.  The  tumor  is  covered  by  normal  or  but 
slightly  altered  integument  and  gradually  obstructs  the  nostrils  and 
deforms  the  nose.  It  may  invade  the  lips,  gums  and  neighboring 
structures.  It  seldom  ulcerates,  but  is  the  seat  of  pain  without  in- 
flammatory symptoms.     It  is  probably  a  mycotic  affection. 

Excision  must  be  thoroughly  done  if  return  of  the  growth  is  to 
be  prevented.  Plastic  procedures  may  then  be  required  to  cure  the 
deformity  due  to  the  removal  of  tissue. 

Abnormal  Growth  of  Hair. 

Patches  of  hair  on  the  faces  of  women  or  on  unusual  portions  of 
men's  faces  require  treatment  of  a  surgical  character.  Pigmented  and 
vascular  moles  are  at  times  covered  with  hair. 


SKIN  DISEASES  REQUIRING  SURGICAL  TREATMENT  81 

If  the  mole  or  hairy  patch  is  small,  it  may  be  excised  by  elliptical 
incisions  with  a  sharp  and  delicate  knife  like  those  used  in  cataract  ex- 
tractions. The  incisions  must  be  carried  down  to  the  subcutaneous 
tissue,  or  the  hair  bulbs  will  not  be  entirely  removed.  Very  delicate 
needles  and  sutures  should  be  employed  to  close  the  wound.  If  the 
hypertrichosis  is  extensive,  this  method  cannot  be  employed.  Then 
the  hair  follicles  should  be  destroyed  by  electrolysis.  This  means 
may  be  resorted  to  in  small  areas  of  hairiness  if  the  operator  prefer. 

in  destroying  the  hair  papilla  by  electrolysis,  the  operator  thrusts 
the  needle  into  each  hair  follicle  and  pushes  its  point  down  to  the  hair 
papilla  at  the  bottom.  The  needle  Is  attached  to  the  negative  pole 
of  a  galvanic  battery,  the  positive  electrode  of  which  is  held  in  the 
hand  of  the  patient.  The  circuit  is  then  made  and  the  current  passes 
through  the  hair  papilla,  causing  a  few  bubbles  of  gas  to '  escape. 
The  destruction  of  the  hair  papilla  by  electrolytic  action  permits  the 
operator  to  pull  out  the  hair.  The  pain  is  slight,  but  the  operation 
is  tedious  as  each  hair  must  be  treated  separately  and  skilfull}^ 
The  cutaneous  wheals  produced  by  the  current  soon  disappear  and 
little  or  no  scarring  remains. 

The  battery  should  contain  six  or  more  cells,  and  the  current 
should  be  of  about  two  to  four  milliamperes.  The  sensitiveness  of 
the  skin  to  the  current  varies  with  the  patient  and  the  region  of  the 
face.  The  needle  should  be  fitted  in  a  properly  insulated  handle; 
it  must  be  thrust  down  the  follicle  so  as  not  to  be  passed  through  its 
wall,  but  to  reach  the  hair  papilla  at  the  bottom.  Hyde  recommends 
that  the  patient  make  and  break  the  current  by  holding  the  handle  of 
the  positive  electrode  in  one  hand  and  pressing  its  moist  sponge  against 
the  plam  of  the  other  hand  at  the  command  of  the  surgeon.  The 
needle  should  be  properly  fixed  in  the  follicle  before  the  current  is 
allowed  to  pass  through  the  patient's  tissues.  Local  anesthetics  are 
unnecessary  and  are  said  to  be  undesirable.  Two  or  three  dozen 
hairs  are  about  as  many  as  can  be  removed  in  an  hour's  sitting. 

Atrophy  of  hair  follicles  may  be  produced  by  proper  applications 
of  the  X-ray.  The  surrounding  tissues  must  be  protected  from  the 
influence  of  the  ray  by  means  of  a  leaden  shield.  Depilatory  pastes 
and  ointments  simply  destroy  the  hair  filaments,  which  grow  again 
in  a  couple  of  weeks. 

Absence  or  Loss  of  Hair. 

Congenital  absence  of  the  hair  of  the  eyebrows,  eyelids  and  beard 
or  loss  of  hair  in  these  regions  may  be  ver}^  disfiguring.  Sometimes 
the  loss  of  hair  is  the  result  of  constitutional  states,  such  as  syphilis. 

6 


82 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


or  acute  fevers;  at  other  times  it  is  due  to  localized  cutaneous  inflam- 
mations, vegetable  parasites  affecting  the  hair  or  to  obscure  neurotic 
causes. 

Treatment  of  the  constitutional  state  causing  alopecia,  local 
remedies  to  destroy  the  parasite,  and  stimulating  applications  to  in- 
crease the  blood  flow  to  the  bald  areas  must  be  adopted. 

Among  the  local  measures  are  ointments  such  as  chrysophanic  acid 
gr.  X,  glycerine  ii^xl,  petrolatum  5vii,  lotions,  such  as  corrosive  sub- 
limate gr.  V,  alcohol  fSii,  glycerine  f§ss,  rose  water  fgvi;  frequent 
blistering  with  cantharidal  collodion;  and  faradization  of  the  skin 
with  a  stiff  wire  brush.  Hypodermics  of  pilocarpine  hydrochlorate 
gr.  1  /8  have  been  thought  to  induce  a  growth  of  hair. 

The  disfigurements  due  to  local  baldness  in  men's  beards  and  mus- 
taches may  be  minimized  by  keeping  the  parts  shaved.  It  is  possible 
that  the  noticeable  whiteness  of  the  bald  spot  observed,  even  when 
the  surrounding  hair  is  shaved,  might  be  made  less  conspicuous  by 
tattooing  with  some  pigment.  Black  pigments  applied  to  the  skin 
will  render  absence  of  eyebrows  or  lashes  much  less  conspicuous. 

Tumors  of  the  Skin. 

Benign  growths  of  the  skin  of  the  face  require  operative  removal 
because  of  the  disfigurement  they  cause;  and  because  some  of  them 


Fig.   34. — Dermoid  cyst  of  nose.      (Lannelogue.) 

have  a  tendency,  especially  in  the  aged,  to  assume  malignancy.  The 
malignant  tumors  always  require  prompt  and  radical  removal,  on 
account  of  their  tendency  to  invade  surrounding  tissues  and  destroy 
life.  The  non-malignant  growths  should  be  excised  so  as  to  leave  as 
little  scarring  as  possible.     The  chief  consideration  in  treating  malig- 


SKIN  DISEASES  REQUIRING  SURGICAL  TREATMENT  83 

nant  tumors,  however,  is  to  get  rid  of  all  infected  tissues  and  the 
connected  lymph  nodes,  but  even  in  such  cases  there  is  often  a  possibil- 
ity of  lessening  the  degree  of  deformity  by  properly  planned  incisions. 

A  conspicuous  form  of  tumor  of  the  face  is  the  yellowish,  flattened 
and  superficial  neoplasm  of  the  skin  called  xanthoma,  which  is  most 
frequently  seen  upon  the  eyelids.  It  may,  however,  occur  on  the  nose, 
cheeks  and  ears.  It  should  be  excised,  scraped  away,  or  treated  by 
electrolysis.  If  the  patch  of  xanthoma  is  situated  upon  the  eyelids, 
the  incisions  must  be  so  superficial  and  so  planned  as  not  to  cause 
eversion  of  the  lids. 

Tuberculosis  of  the  skin  or  lupus,  syphilitic  gumma  and  epithelioma 
may  be  confounded  when  they  occur  in  the  face.  I  was  once  consulted 
as  to  the  propriety  of  amputating  a  portion  of  an  old  lady's  nose, 
which  was  supposed  to  be  the  seat  of  a  lupous  or  epitheliomatous 
ulceration.  I  made  a  diagnosis  of  tertiary  syphilis,  which  was  con- 
clusively proved  by  the  rapid  improvement  under  mercury  and 
iodides. 

Lupus  is  a  cutaneous  tuberculosis,  and  may  cause  during  its 
protracted  existence  the  most  extensive  ravages;  leading  to  ectropion, 
a  shrunken  beak-like  nose,  complete  destruction  of  the  external  nose, 
contraction  of  the  opening  of  the  mouth  and  distortion  of  the  lips 
and  ears. 

The  disease  is  to  be  removed  by  dissecting  out  the  tuberculous 
skin  and  covering  the  space  with  Thiersch's  skin  shavings,  by  scrap- 
ing the  diseased  structures  away  with  a  sharp  curette,  or  by  applying 
strong  caustics,  such  as  a  solution  of  zinc  chloride,  and  ethylate  of 
sodium.  Hyde  recommends  the  application  to  the  scraped  area  of  a 
flat  negative  electrode  as  an  accessory  to  the  curetting.  The  current 
should  be  of  from  5  to  8  milliamperes. 

Instead  of  these  surgical  measures  the  surgeon  may  first  try  the 
local  use  of  parasiticides,  which  have  strong  advocates.  Corrosive 
chloride  of  mercury  dissolved  in  water  or  tincture  of  benzoin  (gr.  i  —  ii 
ad  f  oi)  may  be  applied  upon  cloths,  or  an  ointment  of  the  same  strength 
may  be  used.  Solution  of  salicylic  acid  in  castor  oil  (gr.  xv  — xxx 
ad  f^i),  iodoform,  or  creosote  may  be  similarly  employed.  These 
remedies  directed  to  the  destruction  of  tubercle  bacillus  are  said  to  be 
efficient. 

Before  using  chemical  agents  as  caustics  or  parasiticides  it  is  wise 
to  get  rid  of  the  crusts  by  the  use  of  oily  applications.  When  the 
lupous  tissue  has  been  removed  the  resulting  ulcer  is  to  be  treated 
on  general  surgical  principles,  as  would  be  an  ulcer  produced  in  any 
other  manner. 


84  •       SURGERY  OF  DEFORMITIES  OF  THE  FACE 

The  treatment  of  cutaneous  tuberculosis  with  the  X-ray  or  with 
the  Finsen  light  is  probably  more  satisfactory  than  the  methods  just 
mentioned. 

Erythematous  lupus  is  to  be  treated  at  first  by  tincture  of  green 
soap,  sulphur  ointment,  salicylic  acid  and  collodion  and  similar 
stimulating  lotions  or  ointment.  If  these  are  unsatisfactory,  electrol- 
ysis, curetting,  or  multiple  punctures  or  incisions  with  a  small  knife 
or  needle  may  be  employed. 

Syphilitic  lesions  of  a  tertiary  kind  may  destroy  the  surface  of  the 
nose  and  other  portions  of  the  face  so  rapidly  that  an  early  diagnosis 
of  the  character  of  the  lesion  is  very  important.  Full  doses  of  mercury 
and  potassium  or  sodium  iodide  should  be  given  promptly  and  regularly. 
The  antisyphilitic  treatment  must,  be  active  here  as  in  syphilitic 
disease  of  the  central  nervous  system,  since  the  tissues  destroyed  can- 
not be  regained.  Great  disfigurement  results  from  allowing  unrecog- 
nized syphilitic  ulceration  to  exert  its  destructive  effects.  My  own 
preference  is  to  give  about  gr.  1/3  of  green  iodide  of  mercury  .and  gr. 
1  of  tannic  acid  before  meals;  and  gr.  xxx  of  potassium  iodide  after 
meals.  By  taking  a  meal  between  the  two  medicines  there  is  little 
danger,  if  any  exists,  of  the  patient  suffering  from  a  chemical  reaction 
between  the  remedies  in  the  stomach.  These  doses  may  be,  and  not 
infrequently  must  be,  largely  increased.  One  thousand  grains  of 
potassium  iodide  daily  is  not  too  large  an  amount  in  some  cases. 

Ehrlich's  preparation,  termed  salvarsan,  may  prove  itself  more 
valuable  than  mercury  and  the  iodides  in  syphilitic  lesions. 


CHAPTER  VIII. 

DEFORMITIES  OF  THE  MOUTH  AND  LIPS. 

The  chief  congenital  deformity  of  the  mouth  is  harelip;  and  it, 
with  its  complications,  affords  ample  opportunity  for  the  constructive 
skill  of  the  reparative  surgeon.  Other  congenital  defects  are  atresia 
oris,  macrostoma,  microstoma,  cleft  of  the  lower  lip,  hypertrophy 
of  the  lips  and  excessive  eversion  of  the  lower  lip. 


Fig.  35. — Deformity  of  mouth  and  eyeKds  from  burns  causing  sloughing, 
lower  lip  shown.      {Patient  of  author.) 


Incision   to   improve 


Distortion  of  the  mouth  and  lips  and  deficiencies  of  the  lips  and 
cheeks  not  infrequently  occur  as  the  result  of  cicatricial  contraction  from 
burns,  wounds,  or  sloughing.  Sometimes  ugly  disfigurements  remain 
after  the  removal  of  malignant  or  other  tumors  and  after  accidental 
injuries,  such  as  bites  or  incised  wounds. 

The  sloughing  following  burns  of  the  face  often  causes  frightful 

85 


86 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Fig.  36. — Same  patient  as  figure  35. 
Outline  of  flap  from  cheek  to  repair 
upper  lip  shown. 


Fig.  37. — Same  patient  as  figure  36. 
New  position  of  flap  from  cheek  indicated 
by  shaded  area.  Sutures  in  cheek  indi- 
cated. 


Fig.  38. — Same  patient  as  figure  37.  Eyelids 
mproved,  glass  eye  inserted.  Mouth  is  partially 
reconstructed.  Compare  lips  with  those  in  figures 
33  and  34. 


Fig.  39. — Myxoma  of  cheek  and  lip 
which  was  excised,  and  tissues  displaced 
so  as  to  reconstruct  cheek,  thereby  clos- 
ing mouth  almost  completely.  {Author's 
patient.) 


DEFORMITIES  OF  THE  MOUTH  AXD  LIPS  87 

facial  disfigurement,  which  may  involve  nose,  eyelids  and  cheek  as  well 
as  the  mouth. 

Occlusion  or  Contraction  of  the  Mouth. 

The  treatment  of  both  congenital  atresia  oris  and  cicatricial  con- 
traction is  based  on  the  same  general  principles. 

In  the  former  case  the  occluding  membrane  must  be  divided  and 
adhesions  of  the  lips  prevented,  especially  at  the  corners  of  the  mouth, 
by  suturing  the  mucous  membrane  to  the  skin.  In  the  latter,  a 
horizontal  incision  must  be  made  outward  from  the  orifice  representing 
the  mouth.  The  mucous  membrane  must  then  be  drawn  and  sutured 
into  the  end  of  the  incision  so  as  to  prevent  reunion  of  the  edges  of  the 
wound.  It  may  be  best  to  form  at  first  an  opening  in  the  cheek  lined 
with  mucous  membrane.     In  some  cases  a  V-shaped  piece  of  the  cheek 


Fig.  40. — Condition  of  mouth  after 
excision  of  tumor.  Same  patient  as 
figure  39. 


Fig.  41. — Reconstruction  of  mouth 
showing  opening  in  cheek  lined  with 
mucous  membrane.  Same  patient  as  in 
figure  40. 


may  be  removed  with  the  point  of  the  V  extending  outward,  and  the 
mucous  membrane  and  skin  are  then  stitched  together.  In  cicatricial 
cases  it  will  probably  be  better  to  remove  no  tissue. 

A  circular  mouth  due  to  cicatricial  contraction  might  perhaps  be 
enlarged  by  cutting  vertically  from  the  center  of  the  opening  down- 
ward into  the  tissues  covering  the  front  of  the  chin.  The  mouth  might 
then  be  enlarged  laterally  by  sliding  upward  the  structures  covering 
the  front  of  the  jaw. 

Microstoma,  or  small  mouth,  is  sometimes  the  result  of  imperfect 


88  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

development  of  the  lower  jaw.  It  may  require  a  plastic  procedure 
somewhat  like  those  just  described.  Contraction  of  mouths  which 
have  been  enlarged  by  operation  may  perhaps  be  prevented  to  some 
extent  at  least  by  wearing  for  a  time  or  at  intervals  a  wooden  or 
celluloid  stretcher,  shaped  so  as  to  lie  firmly  between  the  open  lips. 

Macrostoma  and  Accidental  Increase  in  Size  of  the  Mouth. 

Imperfect  closure  of  the  branchial  fissures  may  cause  horizontal 
cleft  at  one  or  both  sides  of  the  mouth  extending  into  the  cheek  and 
causing  the  condition  termed  macrostoma.  This  may  be  continued 
outward  toward  the  ear  as  a  cicatricial  line  or  groove  in  the  cheek,  or 
be  associated  with  deformities  of  the  auricle  or  with  small  chondromas 
of  the  cheek.     This  is  to  be  treated  by  freshening  the  edges  of  the 


Fig.  42. — Congenital  lateral  fissure  of  mouth.     {Author's  case.) 


fissure  and  applying  sutures  very  much  as  in  the  case  of  the  vertical 
clefts  called  harelip.  The  cicatricial  groove  may  be  dissected  out  and 
the  skin  drawn  together  with  sutures;  and  the  cartilaginous  tumors 
excised.  Similar  deficiencies  in^  the  closure  of  the  fetal  structures 
cause  fissures  of  the  upper  and  lower  lips,  running  sometimes  up  to 
the  orbits  or  down  to  the  sternum.  Occasionally  a  mere  scar-like 
line  is  seen  in  the  baby's  lip,  as  though  an  intra-uterine  cure  of  a  fissure 
in  the  lip  had  taken  place.  The  vertical  fissure  of  the  lip  is  usually 
at  one  side  of  the  median  line,  but  it  may  be  in  the  middle  in  either 
the  upper  or  lower  lip.  Congenital  fistules  are  sometimes  seen  on  the 
free  edge  of  the  lower  lip. 

These  fissures  must  all  be  closed  by  similar  operative  procedures. 
As  the  greatest  variety  of  complications  occurs  in  fissures  of  the  upper 


DEFORMITIES  OF  THE  MOUTH  AND  LIPS 


89 


lip,  a  detailed  and  comprehensive  discussion  of  this  branch  of  repara- 
tive surgery  will  be  deferred  until  these  deformities  are  under 
consideration. 

Operations  within  the  mouth  may  demand  splitting  the  cheek  from 
the  mouth  outward,  in  order  to  obtain  access  to  the  site  of  operation. 
Such  wounds  may  be  closed  with  little  deformity. 

Hypertrophy  of  the  Lips, 

The  lips  may  be  enlarged  from  a  true  interstitial  increase  of  all  the 
structures;  from  a  lymph-edema  due  to  obstruction  of  the  lymphatic 
circulation;  from  chronic  inflammation,  and  from  the  presence  of  an 
angioma  or  other  tumor  in  the  substance  of  the  lip. 

Children  the  subjects  of  cretinism,  tuberculosis  or  inherited 
syphilis  sometimes  have  enlarged  lips.     The  condition  is  ameliorated 


Fig.  43. — Angioma  of  upper  lip.      (Dr.  Edward  Marti/i's  patient  ) 


or  entirely  removed  as  the  patients  regain  a  normal  condition  of 
health  under  hygienic,  specific  and  tonic  treatment.  Thyroid  ex- 
tract may  be  serviceable  in  the  cretinoid  cases. 

Hypertrophied  lower  lip  may  be  altered  by  excision  of  a  A'-shaped 
portion  in  the  median  line  with  the  apex  of  the  Y  near  the  chin.  This 
will  diminish  the  great  width  of  the  enlarged  lip.  Sutures  of  silk 
or  linen  are  used  on  both  the  cutaneous  and  mucous  surfaces.  Hare- 
lip pins  are  of  no  special  advantage  in  labial  surgery  and  their  use 
should  always  be  avoided.     If  the  lip  is  more  hypertrophied  on  one 


90  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

side  of  the  median  line  than  the  other,  the  incision  on  that  side  should 
be  further  from  the  middle  of  the  lip  than  the  other.  The  thickness 
of  the  lip  may  require  a  second  operation  after  healing  of  the  first  wound 
has  taken  place.  This  consists  in  removing  a  wedge  of  tissue  by 
means  of  incisions  running  across  the  free  border  of  the  lip  and  going 
deeply  into  its  structure.  The  wounds  make  a  narrow  ellipse  on  the 
edge  of  the  lip,  extend  across  the  mouth,  and  go  down  to  the  full 
depth  of  the  lip  in  such  a  manner  that  the  planes  of  the  two  cuts 
shall  come  together  at  the  level  at  which  the  lip  is  attached  to  the 
lower  jaw.  This  operation  removes  a  long  transverse  thin  wedge  of 
the  muscular  part  of  the  lip.  The  work  must  be  skilfully  done  to 
prevent  unseemly  puckering  of  the  lip.  A  similar  operation  may  be 
done  for  reducing  the  size  of  the  hypertrophied  upper  lip. 

A  hypertrophied  lip  may  be  of  a  raspberry  color  because  of  di- 
lated cutaneous  capillaries.  This  discoloration  must  be  treated  as  are 
the  so-called  port  wine  marks,  by  cauterization  with  red  hot  needles, 
multiple  scarifications,  injections  of  boiling  water  or  other  operative 
means. 

Hypertrophy  of  the  upper  lip  is  to  be  dealt  with  in  a  similar  manner 
to  that  advocated  for  enlarged  lower  lip. 

Eversion  of  the  Lips. 

The  lips  are  sometimes  turned  outward  because  of  an  abnormal 
enlargement  of  the  mucous  glands  of  the  organ.  This  gives  rise  at 
times  to  a  protrusion  of  mucous  membrane  which  causes  what  has  been 
called  double  lip. 

Double  Lip. 

A  true,  double  lower  lip  occurs,  though  rarely,  as  a  congenital 
malformation.  Upon  the  mucous  edge  of  the  lip  is  seen  a  transverse 
groove  separating  two  labial  formations.  As  a  result  an  abnormal 
thickness  of  the  duplicated  organ  is  apparent,  especially  when  the  lip 
is  everted.  In  a  case,  seen  by  me  some  years  ago,  there  was  at 
each  end  of  the  groove  a  sinus,  lined  with  mucous  membrane,  leading 
into  the  muscular  substance  of  the  lip.  A  transverse  elliptical  wedge 
excision  of  the  inner  lip,  including  these  congenital  sinuses,  reduced 
the  bulk  of  the  protruding  lower  lip.  Sutures  brought  the  edges  of  the 
wound  together  and  relieved  the  deformity.  This  condition  differs 
from  the  hypertrophy  of  the  single  lower  lip  with  increase  of  the 
mucous  surface,  to  which  the  term  double  lower  lip  is  sometimes 


DEFORMITIES  OF  THE  MOUTH  AND  LIPS 


91 


applied.     The  operation  for  the  reduction  of  such  a  bulky  organ  is 
practically  the  same  as  in  true  double  lip. 

This  condition  is  remedied  by  a  transverse  straight  incision  along 
the  mucous  surface  of  the  lip  and  the  excision  of  the  redundant  gland- 
ular tissue.     The  mucous  membrane  is  then  sutured.     It  will  be  often 


Fig.  44. — True  double  lip  cured  by  excision.      (Author's  patient.) 

necessary  to  remove  some  of  the  mucous  membrane.  Two  incisions 
should  then  be  made  so  as  to  make  a  narrow  ellipse  across  the  lip  from 
side  to  side. 

A  somewhat  similar  hypertrophy  of  the  glandular  tissue  and 
mucous  membrane  of  the  lip  is  often  seen  when  the  lips  are  everted 
by  cicatricial  contraction  of  the  skin  and  subcutaneous  tissue  after 


Fig.  45. — Hypertrophy  of  lower  Up  cured  by  excision  of  tissue.      (Author's  patient.) 

burns  of  the  face.  The  exposure  of  the  mucous  membrane  to  irri- 
tation causes  the  increase.  In  these  cases  the  skin  scars  must  be  dealt 
with  by  plastic  operations  to  relieve  tension,  before  the  mucous  mem- 
brane is  excised.  The  latter  operation  will  be  ineffectual,  unless  the 
tension  of  the  scar  tissue  is  first  relieved. 


92 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


It  is  said  that  eversion  of  the  lower  lip  occurs  from  preternatural 
length  of  the  frenum  allowing  protrusion  and  drooping.  If  this  is 
found  to  be  the  cause  a  V-shaped  piece  may  be  excised  from  this 
fold  of  tissue,  in  order  to  draw  the  lips  upward  and  inward. 

Everted  lips  may  also  be  turned  inward  by  excising  a  horizontal 
wedge-shape  piece,  beginning  at  the  mucous  surface  and  extending 
through  to  the  lower  surface  of  the  skin,  but  not  cutting  through  the 
skin.  If  the  latter  is  divided,  an  external  linear  scar  will  be  made. 
This,  however,  is  not  important  if  the  correction  of  the  deformity 
makes  such  external  wound  necessary. 


Fig.  46. — Flexion  of  head  from  sloughing  after  burns  treated  by  incision  and  long  flaps  from  back 
brought  around  neck  like  a  collar.     (Author's  patient.) 


The  great  eversion  of  the  lower  lip  clue  to  burns  may  be  improved 
by  a  V-shaped  incision  with  its  base  corresponding  with  the  edge  of 
the  lip.  This  allows  the  skin  to  be  slipped  up  toward  the  mouth  and 
the  lip  raised  until  it  lies  against  the  gum  and  teeth.  The  hyper- 
trophied  mucous  membrane  due  to  exposure  may  in  some  cases  re- 
quire excision.  This  will  aid  in  drawing  the  lip  upward  and  inward. 
The  upper  lip  is  perhaps  more  apt  to  be  dragged  by  cicatricial  influences 
directly  upward  than  to  be  everted  like  the  lower  lip  under  the  same 
circumstances.     It  may  be  displaced  downward  by  a  similar  sliding 


DEFORMITIES  OF  THE  MOUTH  AND  LIPS 


93 


of  a  V-shaped  flap;  or  it  may  require  the  insertion  of  a  thick  piece  of 
the  cheek  to  fill  the  gap  left  after  the  drawn  up  portion  of  lip  has  been 
freely  separated  from  adjacent  structures.  In  these  cases  the  V  must 
embrace  all  the  everted  portion  in  its  base  and  must  be  long  enough 
to  permit  sufficient  sliding. 

Wholethickness  skin  grafts  from  the  thigh  or  abdomen  or  peduncu- 
lated flaps  from  arm  or  hand  may  be  required  to  reconstruct  lips  lost 
by  sloughing  from  burns  or  other  causes. 


Fig.  47. — Ectropion  of  lower  lip  after  severe  burn.     Greatly  improved  by  flaps  from  back. 
{D?\  Joseph  M.  Spellissy's  patient.) 


The  head  may  be  flexed  on  the  chest  by  scar  contraction  and 
thus  growth  of  the  jaw  and  lower  part  of  the  face  may  be  impeded  in 
children.  Sometimes  restitution  can  be  obtained  by  a  V-shaped  incis- 
ion of  the  chest  and  neck  and  sliding.  At  other  times  it  is  best  to 
take  two  long  flaps  from  the  scapular  regions  of  the  back.  These  are 
brought  around  the  front  of  the  neck  like  a  collar  to  meet  in  the  middle 
line  after  a  dissection  has  been  made  to  release  the  head  and  allow  it  to  be 
held  erect.  This  method  was  used  in  the  boy  shown  b}''  the  accom- 
panying photograph. 

After  removal  of  malignant  disease  of  the  corner  of  the  mouth 
or  of  the  lips  it  may  be  necessary  to  construct  a  portion  of  or  an  entire 
lip  or  to  fill  in  an  opening  left  in  the  cheek.  A  small  opening  in  cheek 
ma}'-  be  closed  by  a  crescentic  flap  turned  up  from  side  of  neck. 


94  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

If  the  cheek  is  largely  destroyed,  it  may  be  best  to  dissect  a  U- 
shaped  flap  from  the  neck,  turn  it  upward  and  thrust  it  through  a 
buttonhole-like  incision  made  along  the  lower  margin  of  the  jaw. 
In  this  manner  the  skin  surface  of  the  flap  is  within  the  mouth  and  ad- 
hesion does  not  take  place  between  the  surface  of  the  flap  and  the  raw 
surface  of  the  gums.  The  outside  of  the  flap  which  makes  the  cheek 
is  covered  with  skin  grafts  or  shavings  either  at  once  or  at  a  later  time. 
This  operation  is  very  valuable  when  cicatricial  ankylosis  of  the  jaws 
complicates  the  loss  of  the  tissue  of  the  cheek.  If  the  skin  of  the  neck 
is  covered  with  beard,  the  hair  may  be  gradually  removed  by  electrolysis 
or  the  X-ray,  before  the  flap  operation  is  performed. 


Fig.  48  — Epithelioma  near  eye  excised  and  Hap  from  temple  used  to  fill  space,  so  as  to  prevent 
aversion  of  eyelid.     Temporal  wound  covered  with  skin  shavings.      {Author's  patient.) 

The  cheek  is  not  infrequently  adherent  to  the  gum  when  sloughing 
has  occurred  from  the  abuse  of  mercurials  as  a  medicine,  exanthem- 
atous  fever,  or  other  causes.  Sometimes  it  is  possible  to  dissect  the 
cheek  loose  and  make  intra-oral  flaps  of  mucous  membrane,  which  can 
be  inserted  on  the  inside  of  the  cheek  or  on  the  gum  so  as  to  prevent  the 
apposition  and  consequent  adhesion  of  live  raw  surfaces.  The  thrust- 
ing of  a  U-shaped  flap  from  the  neck  through  a  buttonhole  may  be 
much  better. 

Operations  for  malignant  disease,  carbuncular  inflammation, 
syphilitic  ulceration  and  sloughing  may  destroy  the  upper  or  lower 
lip  and  render  the  formation  of  an  entire  lip  necessary  to  relieve  the 
deformity.  This  operation  is  called  cheiloplasty.  This  reconstruc- 
tive problem  will  be  found  discussed  in  Chapter  XL 

If  the  lost  portion  of  the  lip  is  near  the  angle  of  the  mouth,  the 
tissue  to  reconstruct  the  organ  may  be  taken  from  the  other  lip. 


DEFORMITIES  OF  THE  MOUTH  AND  LIPS 


95 


The  two  appended  cuts  show  an  incision  for  a  case  of  this  kind,  and  the 
result.  The  fiap  from  the  upper  lip  was  drawn  downward  and  twisted 
into  place  so  as  to  successfully  close  the  gap. 

Sometimes  the  loss  of  tissue  of  lips  and  cheek  may  be  so  great  that 


Fig.  49. — Tumor  of  lower  lip  excised  and  lip  repaired  with  flap  from  upper  lip. 

meloplasty,  or  formation  of  the  cheek,  and  the  coincident  cheiloplasty, 
or  formation  of  the  lip,  are  best  performed  by  resecting  one-half  of 
the  lower  jaw.  This  preliminary  operation  lessens  the  bulk  of  the 
bony  framework  of  the  face  and  the  facial  defect  requires  less  material 
for  its  closure. 


Fig.  50. — Appearance  of  patient  after  reconstruction  of  lip  by  method  shown  in  figure  49. 


Deformities  Due  to  Removal  of  Bone  and  Paralysis. 

Considerable  deformity  of  the  lower  part  of  the  face  may  arise 
after  excision  of  the  mandible,  or  lower  jaw,  for  necrosis  or  tumor, 
because  the  muscles  displace  the  portion  which  is  left.  If  this  is  held 
in  normal  position  for  a  time  after  the  operation,  the  tendency  to 


96  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

displacement  disappears  and  marked  deformity  does  not  occur. 
Westlake  made  an  intra-oral  splint  before  operation  in  such  a  case  and 
after  excision  held  the  remaining  portion  of  bone  in  proper  position  by 
it.  It  consisted  of  gold  caps  fitted  to  the  teeth  of  the  upper  and  lower 
jaw  and  an  attached  removable  spring.  This  held  the  portion  of  the 
mandible  which  remained  in  normal  position  and  was  discarded  in  a 
few  months  when  the  muscles  ceased  to  exert  a  displacing  tendency. 
A  vulcanite  cheek  plumper  was  then  ada;pted  to  fill  out  the  collapsed 
cheek  due  to  the  absent  portion  of  the  jaw^'^ 

For  cicatricial  ankylosis  of  the  jaw,  Weir^  cut  away  the  scar  tissue 
within  the  mouth;  and  then  dissected  a  flap  of  skin  from  the  neck 
which  was  tucked  through  a  vertical  incision  made  in  front  of  the 
masseter.  Thus  a  non-contracting  skin  flap  was  put  inside  of  the  mouth 
and  the  ankylosis  cured.  This  method  deserves  consideration  in 
cases  where  puckering  of  the  lips  and  cheeks  has  occurred  from  intra- 
oral adhesions  and  scar  contraction. 

The  obliquity  of  the  mouth  due  to  facial  palsy  is  disfiguring. 
Garretson  treated  such  a  case^  in  which  the  palsy  was  incurable,  by 
excising  an  elliptical  portion  of  tissue  from  the  cheek  in  a  line  run- 
ning from  the  middle  of  the  nose  to  the  angle  of  the  lower  jaw.  This 
-raised  the  corner  of  the  mouth  which  drooped  on  the  paralyzed  side. 
When  the  patient's  features  were  in  repose  the  improvement  was 
marked;  but  smiling  or  laughter  caused  deformity,  because  there  was 
no  motion  on  the  paralyzed  side.  This  was  corrected  to  a  considerable 
extent  by  a  hair-pin,  thrust  into  the  hair,  to  one  end  of  which  a  cord 
of  rubber  was  attached.  This  rubber  band  or  artificial  muscle  was 
applied  to  the  cheek  by  a  small  piece  of  inconspicuous  pink  court 
plaster.     The  pin  and  rubber  were  concealed  by  the  overhanging  hair. 

Cystic  and  other  Tumors  of  the  Lips. 

Tumors  of  the  lips  are  to  be  treated  on  general  principles  and  re- 
moved by  such  incisions  as  will  insure  the  least  scarring  and  cicatricial 
contraction.  The  scar  should  if  possible  be  placed  on  the  mucous 
surface  of  the  lip,  as  it  is  then  practically  unnoticeable.  This  can 
only  be  clone  as  a  rule  when  the  tumor  is  small,  or  when  the  growth  is 
cystic.  Malignant  growths  usually,  and  benign  growths  sometimes, 
require  such  extensive  excision  that  cheiloplastic  operations  of  an 
extensive  character  may  be  demanded  to  reconstruct  a  new  lip.     This 

1  "Medical  Record,"  Nov.  18,  1893,  p. 647. 

2  "Annals  of  Surgery,"  Nov.  1898,  p.  656.     ,; 
^  "Oral  Surgery,"  Edition  1895,  p.  746. 


DEFORMITIES  OF  THE  MOUTH  AND  LIPS  97 

necessity  should  not  deter  the  operator  from  making  a  free  excision 
of  the  tissue  at  a  sufficient  distance  from  the  disease.  The  contiguous 
lymphatic  nodes  beneath  the  jaw  should  always  be  excised  at  the  time 
of  the  primary  operation  on  the  lip. 

Affections  of  the  Gums. 

The  various  forms  of  epulis  may  cause  facial  disfigurement  and 
demand  surgical  treatment.  The  removal  of  sections  of  the  jaw  bone 
or  of  teeth  alone  may  be  necessary  in  their  efficient  extirpation.  In 
cases  of  malignant  epulis  excision  of  the  jaw  and  removal  of  the  lymph 
nodes  is  imperative.  Artificial  dentures  and  prosthetic  appliances 
to  take  the  place  of  the  lost  bone  and  keep  the  cheeks  distended  may 
be  needed.  Reference  has  been  made  to  some  of  these  devices  in 
discussing  deformities  of  the  mouth.  The  art  of  a  mechanical  dentist 
is  usually  needed  to  supplement  the  skill  of  the  surgeon. 

Cleft  of  the  alveolus  occurs  in  association  with  harelip  or  cleft 
palate.  It  may  be  treated  by  osteoplastic  operation  at  the  time  the 
harelip  is  operated  upon,  if  that  condition  is  present.  The  opposing 
borders  of  the  cleft  may  be  freshened,  the  alveolus  divided  by  saw  or 
forceps  on  each  side,  and  the  piece  of  bone  and  mucous  membrane  be 
then  forcibly  pushed  together  so  as  to  close  the  gap.  A  wire  suture 
passed  through  drill  holes  will  maintain  apposition  and  permit  bony 
union.  This  is  my  customary  method  in  dealing  with  harelip  and 
cleft  alveolus  associated  with  cleft  of  the  hard  palate.  When  the  jaw 
grows  and  the  teeth  develop,  small  fissures  may  close  spontaneously 
to  a  sufficient  extent  to  bring  the  edges  in  contact. 

Dental  Disfigurements. 

Dental  irregularities  and  malformations  and  discolored  teeth  require 
the  skilful  work  of  a  trained  dentist  to  meet  the  problems  of  preven- 
tion and  relief.  This  branch  of  oral  surgery  has  been  greatly  developed 
in  recent  years.  The  worst  deformities  may  often  be  greatly  bene- 
fitted, especially  in  the  young.  The  removal  of  tartar,  the  bleaching 
of  discolored  teeth,  the  correction  of  irregular  teeth  and  the  adjust- 
ment of  dental  crowns  or  of  artificial  teeth  will  often  convert  a  very 
ugly  mouth  into  a  comely  one.  The  effect  upon  the  expression  of  the 
face  of  these  modifications  of  the  appearance  of  the  mouth  should 
be  remembered.  The  inverted  and  collapsed  lips  of  the  toothless 
mouth  of  the  aged  with  the  tendency  of  the  nose  and  chin  to  approach 
each  other  is  too  well  known  to  need  comment.     This  can  all  be  pre- 

7 


98  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

vented  by  artificial  teeth.     I  am  continually  surprised  at  the  perfec- 
tion in  these  methods  attained  by  skilful  dentists. 

The  result  of  a  clean  mouth,  free  from  carious  teeth,  and  of  teeth 
effective  in  mastication  is  a  healthy  condition  of  the  whole  patient  as 
well  as  an  improvement  in  the  physical  appearance  of  the  face.  The 
comeliness  of  the  patient  is  improved  and  disfiguring  skin  diseases  of 
the  face  are  prevented.  Orthodontia  is  a  science  that  deserves  great 
attention  from  surgeons  as  well  as  dentists. 

Congenital  Hypertrophy  of  Tongue. 

In  this  unusual  condition  the  enlarged  tongue,  protruding  from  the 
mouth,  presses  the  lower  teeth  into  a  more  or  less  horizontal  position 
and  tends  to  give  a  similar  deflection  to  the  body  of  the  mandible. 

The  treatment  should  consist  in  removing  a  horizontal  wedge- 
shape  piece  from  the  front  of  the  tongue  and  applying  sutures.  If 
the  tongue  is  not  very  thick  it  may  be  better  to  cut  out  a  vertical 
wedge  of  tissue.  In  Buck's  case  two  operations  were  done.  The 
first  removed  a  vertical  wedge.  After  heahng,  a  second  excision 
removed  a  horizontal  wedge.  The  jaw  and  teeth  may  subsequently 
be  restored  to  a  normal  position  and  shaped  by  an  apparatus  making 
elastic  pressure  upward  and  backward  on  chin,  assisted  perhaps  by 
intra-oral  appliances  attached  to  the  teeth. 


CHAPTER  IX. 


HARELIP  AND  OTHER  FACIAL  CLEFTS. 


Facial  clefts  are  due  to  incomplete  coalescence,  in  the  first  six 
weeks  of  intra-uterine  life,  of  the  processes,  which  grow  from  the 
mandibular,  or  first,  branchial  arch  and  from  the  frontal  portion  of  the 
head.  The  most  common  congenital  cleft  in  this  region  is  in  the  upper 
lip  and  is  called  harelip.  The  next  in  frequency  is  cleft  of  the  palate 
which  may  or  may  not  involve  both  bone  and  soft  parts.  The  two 
conditions  are  not  infrequently  combined  in  the  same  patient.  Oblique 
clefts  of  the  face,  running  up  to  the  lower  eyelids,  clefts  of  the  nose, 


Fig.  51. — Congenital  fissure  of  upper  lip, 
eyelids  and  cranium. 


Fig.  52. — Congenital  fissure  of  lower 
lip  and  mandible.      (Bryant.) 


and  clefts  of  the  lower  lip  and  jaw  are  occasionally  seen.  A  similar 
developmental  defect,  due  to  imperfect  coalescence  of  the  embryonic 
structures,  causes  the  lateral  fissure  through  the  cheek  called  macro- 
stoma.  This  congenital  deformity  of  the  mouth  has  already  been 
discussed. 

Fissure  of  the  Upper  Lip. 

Cleft  of  the  upper  lip  is  f amiliarlj^  called  harelip,  though  the  fissure 
differs  from  the  normal  labial  split  in  the  hare  by  being  at  one  side 
of  the  median  line.  A  central  fissure  in  the  upper  lip  is  rare.  In  the 
lower  lip  the  onlj^  fissure  of  which  I  have  knowledge  is  in  the  middle. 

99 


100 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


It  is  very  rare.     Occasionally  this  cleft  is  continuous  with  a  cleft  of 
the  lower  jaw,  the  mouth,  the  tongue  and  even  the  neck. 

The  usual  defect  is  lateral  fissure  of  the  upper  lip.  This  may 
be  on  one  side  or  both,  and  often  extends  up  into  the  nostril.  It 
may  be  only  a  notch  in  the  edge  of  the  hp,  or  a  mere  narrow  shining 
line  in  the  skin,  running  up  toward  the  nose.  This  imperfectly 
developed  strip  of  skin  is  not  a  true  scar,  but  a  change  in  the  condition 
of  the  skin  due  to  imperfect  embryonic  union.  The  double  lateral 
cleft  may  have  no  central  piece  between  the  fissures  and  thus  simulate 
a  median  cleft.  The  alveolar  process  of  the  upper  jaw  may  be  cleft, 
as  well  as  the  lip,  on  one  or  both  sides;  and  the  hard  and  soft  palate 


Jat, 

, 

Pt 

f'. 

m 

li'    i^ 

%. 

r-:' 

.           1 

I 

^ 

Fig.  53  .—Unilateral  hareUp  showing 

characteristic  flattening  of  nostril. 

{Author's  -patient.) 


Fig.   54. — Double  harelip  with  pro- 
trusion of  the  intermaxilla. 
{Author's  patient.) 


or  either  alone  may  be  fissured  in  a  similar  way.  The  lip  at  the  edge 
of  the  labial  fissure  is  usually  short  on  the'  side  toward  the  middle  of 
the  mouth.  This  want  of  development  must  be  remembered  when 
operation  is  done  to  reconstruct  the  lip.  Otherwise  the  surgeon  will 
find  an  unseemly  deformity  even  after  the  cleft  has  been  united. 
The  lip  must  be  lengthened  from  nostril  to  mouth,  lest  a  deficiency  or 
notch  will  be  left  in  the  contour  of  the  oral  margin.  Sometimes  the 
lip  on  one  side  of  the  fissure  is  thicker  than  on  the  other. 

In  harelip,  complicated  with  cleft  of  the  bony  palate,  there  may  be 

a  projection  forward  of  the  intermaxillary  bone.     This  protuberance 

is  attached  to  the  septum  of  the  nose.     It  is  often  an  irregular  bulbous 

.process  extending  far  beyond  the  surface  of  the  cleft  lip,  with  the 

accjlumella  of  the  nose  upon  its  upper  surface. 

This  bony  mass  may  be  larger  or  smaller  than  the  fissure  in  the 


HARELIP  AND  OTHER  FACIAL  CLEFTS  101 

alveolus  of  the  upper  jaw.  The  nostril  on  the  side  corresponding  to 
that  of  the  labial  fissure  is  usually  distorted  by  the  ala  being  unsup- 
ported by  a  normal  attachment  to  the  bone.  It  therefore  sinks  and 
changes  the  shape  of  the  opening  of  the  nose,  making  it  sometimes  a 
horizontal  slit. 

Fissures  of  the  lip  must  be  treated  by  operation,  which  should 
always  be  done  under  general  anesthesia.  It  may  be  undertaken  in 
the  simpler  cases,  when  the  infant  is  only  a  few  days  old.  If  the 
deformity  is  complicated  and  requires  a  prolonged  and  bloody  proced- 
ure, it  may  be  necessary  to  wait  until  the  patient  is  several  weeks  or 
months  old. 

There  has  been  considerable  discussion  as  to  the  time  and  manner 
of  managing  cases  of  combined  labial  and  palatal  cleft.  Brophy  of 
Chicago  holds  that  the  cleft  palate  should  be  operated  upon  less  than 
six  months  after  birth,  by  an  osteoplastic  procedure,  and  the  lip  closed 
subsequently.  If  the  operation  in  the  palate  is  delayed  until  the 
patient  is  older  than  six  months,  the  bones  have  become  too  rigid  to 
be  readily  displaced.  He  also  believes  that  the  infant  while  young 
bears  the  shock  of  operation  better  than  after  it  becomes  older.  Many 
surgeons  have  been  in  the  habit  of  closing  the  lip  soon  after  birth,  and 
waiting  two  or  three  years  before  operating  upon  the  deformed  palate. 
The  early  closure  of  the  lip  has  a  beneficial  effect  in  lessening  the  gap 
in  the  roof  of  the  mouth.  It  is  said  that  the  palatal  cleft  may  be 
considerably  diminished  in  width,  if  the  child's  attendant  will  press 
the  two  halves  of  the  upper  jaw  toward  each  other  a  few  times  every 
day  for  a  few  years.  I  formerly  preferred  to  close  only  the  lip  and 
the  alveolar  process  of  the  fissured  jaw  while  the  child  is  very  young; 
but  it  is  better  in  most  instances  to  repair  the  cleft  in  the  roof  of  the 
mouth  at  least  partially  before  closing  the  harelip,  because  of  the 
greater  convenience  in  operating. 

Lane  of  London  lays  great  stress  on  the  desirability  of  closing 
the  cleft  in  the  partition  between  the  nasal  and  oral  cavities  as  early 
as  possible.  In  his  opinion  the  separation  of  these  two  cavities  is 
necessary,  in  order  that  currents  of  respired  air  going  through  the  nose 
forcibly  may  increase  the  size  of  the  naso-pharynx.  Hence  operation 
to  gain  the  best  result  in  cleft  palate  patients  should  be  done,  he 
believes,  while  the  child  is  very  young  and  the  walls  of  the  naso- 
pharynx easily  acted  upon.  Upon  the  proper  expansion  of  the  naso- 
pharynx and  its  accessory  cavities  depends  the  development  of  the 
child's  face  and  the  power  of  correct  pronunciation  in  speech.  Lane 
therefore  urges ^  that  the  palatal  defect  be  closed  on  the  day  after 

1  "Cleft  Palate  and  Harelip,"  London,  1905,  pp.  42  and  63. 


102  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

birth  or  as  soon  after  that  as  possible.  The  harelip  should  in  his 
opinion  never  be  operated  upon  prior  to  the  closure  of  the  cleft  in  the 
palate.  He  usually  operates  upon  the  lip  immediately  after  he  has 
closed  the  gap  in  the  roof  of  the  mouth,  while  the  patient  is  still  under 
the  anesthetic.  His  special  method  of  operating  for  cleft  palate 
will  be  described  later. 

In  operations  for  fissure  of  the  lip,  the  child  may  lie  on  an  operating 
table,  which  is  tilted  so  as  to  keep  the  head  much  lower  than  the 
trunk  and  legs  (Trendelenburg  position),  or  on  a  horizontal  table 
with  the  head  hanging  backward  over  its  end  (Rose's  position) .  These 
devices  assist  in  preventing  blood  being  inspired.  I  have  found  no 
great  difficulty,  however,  in  operating  with  the  patient  in  the  ordinary 
supine  posture  with  the  neck  supported  on  a  small  firm  pillow.  The 
blood  is  readily  and  rapidly  cleansed  from  the  mouth  and  fauces  by 
means  of  sponges  held  in  hemostatic  forceps. 

A  satisfactory  cosmetic  result  is  to  be  expected  only  when  the 
fissure  has  been  closed  without  tension  on  the  sutures,  when  the  short 
side  of  the  lip  is  lengthened,  with  its  mucous  edge  accurately  apposed 
without  leaving  a  notch  or  irregularity,  and  when  the  flattened  ala 
of  the  nose  is  corrected  so  as  to  make  the  two  nostrils  of  a  similar  shape. 
Scarring  from  the  sutures  and  the  incisions  must  be  as  inconspicuous 
as  possible.  Hence  harelip  pins  must  be  dispensed  with,  and  it  is 
oftendesireable  to  insert  the  heavy  sutures  from  the  mucous  surface 
of  the  lip  without  permitting  the  needle  to  perforate  the  skin  surface. 
Then  a  few  very  fine  sutures  may  be  inserted  on  the  cutaneous  surface  of 
the  lip  to  make  the  apposition  absolutely  correct. 

Very  many  lines  of  incision  have  been  proposed  for  reconstructing 
the  fissured  upper  lip,  but  after  all  the  cheiloplasty  may  usually  be 
accomplished  by  slight  modifications  of  the  simple  method  to  be 
described.  When  the  cleft  does  not  go  up  into  the  nostril  the  operative 
steps  are  practically  the  same  as  when  it  does,  though  the  incisions 
need  not  be  as  extensive  as  in  complete  clefts;  and  often  there  is  no 
flattened  nostril  to  be  altered  to  a  more  normal  shape. 

The  lip  on  both  sides  of  the  cleft  must  first  be  dissected  loose  from 
the  upper  jaw,  so  that  its  muscular  tissue  may  be  displaced  toward 
the  median  line  and  downward.  This  separation  is  done  by  thrusting 
a  narrow  knife  between  the  lip  and  the  alveolus,  and  must  in  some  in- 
stances be  carried  upward  nearly  to  the  infra-orbital  foramen  on  the 
side  corresponding  to  the  labial  fissure. 

The  edges  of  the  cleft  must  be  vivified  by  paring  or  splitting  the 
marginal  tissue.  The  former  method  is  usually  preferable.  The 
incisions  must  be  so  placed  as  to  give  a  broad  raw  surface  on  each  side 


HARELIP  AND  OTHER  FACIAL  CLEFTS  103 

of  the  gap  in  the  Up  and  to  give  the  two  edges  the  same  length  from 
nose  to  mouth.  There  must  also  be  sufficient  tissue  along  the  line 
of  proposed  sutures  to  cause  a  little  prominence  at  the  vermilion 
border  of  the  lip.  If  this  is  neglected,  the  cicatricial  shrinking  is 
likely  to  cause  a  shght  notch  at  that  point.  Great  care  must  also  be 
observed  to  have  the  line  of  junction  of  skin  and  mucous  membrane 
exactly  correspond  on  both  sides  of  the  line  of  union. 

The  sutures  which  hold  the  freshened  edges  together  should  be 
of  silkworm  gut,  silk,  linen  or  catgut  and  should  exert  little  tension. 
Harelip  pins  should  never  be  used,  because  they  are  apt  to  make 
unseemly  scars.  To  avoid  external  scarring  a  few  strong  sutures 
may  be  introduced  from  the  mucous  aspect  of  the  lips  without  perforat- 
ing the  skin.  The  skin  surface  may  then  be  held  by  a  few  very  fine 
stitches. 

When  the  fissure  extends  only  a  short  distance  upward  from 
the  mouth,  it  is  called  incomplete.  It  is  remedied  by  detaching  the 
lip  freely  from  the  jawbone  and  paring  the  edges  as  in  complete  fissures. 
The  separation  from  the  bone  need  not  be  as  extensive  as  in  complete 
clefts  extending  up  into  the  nostril.  In  cases  where  the  notch  in  the 
margin  of  the  lip  is  slight  and  the  nostril  is  nevertheless  flattened  and 
widened,  the  operation  attributed  to  Dr.  Charles  H.  Mayo  may  be 
adopted.  He  detaches  the  ala  of  the  distorted  nostril  very  completely 
from  the  underlying  bone,  and  cuts  away  the  muco-cutaneous  surface 
just  at,  and  within,  the  nasal  orifice.  He  then  draws  the  ala  toward 
the  middle  line  by  sutures  applied  to  the  denuded  tissues  in  such  a 
way  as  to  make  a  vertical  line  of  apposition.  This  displacement  of 
the  structures  downward  makes  the  lip  longer  and  eliminates  the 
marginal  notch  in  the  lip.  It  is  only  applicable  in  slight  deformity 
of  the  lip  with  accompanying  flattening  of  the  nostril.  In  other  cases 
it  is  probably  better  to  operate  as  in  complete  cleft. 

The  so-called  Nelaton  method  of  operating  upon  incomplete  clefts 
is  performed  by  making  through  the  lip  an  incision  parallel  to  the 
margin  of  the  lip  and  suturing  this  cut  in  a  vertical  line.  I  do  not 
think  well  of  this  method,  though  my  experience  with  it  has  been  very 
small. 

A  complete  single  cleft  of  the  lip  is  treated  by  free  separation  of  both 
sides  of  the  hp  and  the  flattened  ala  from  the  bone,  paring  the  edges 
of  the  fissure  from  the  nostril  downward  to  the  mouth,  and  carefully 
stitching  the  raw  surfaces  together. 

When  the  knife  comes  near  the  vermilion  edge  of  the  lip,  the  cut 
should  run  toward  the  fissure.  The  lower  part  of  the  incision  is  thus 
angular  near  the  cleft.     This  permits  the  operator  to  give  the  freshened 


104 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


edge  the  necessary  length  by  making  tension  with  forceps  when  he 
inserts  the  sutures.  Still  greater  length  to  either  raw  edge  may  be 
given  by  making  a  horizontal  cut  outward  into  the  cheek  from  the 
angle  in  the  first  incision.  Such  incisions  into  the  cheek  may  be  made 
long  or  short  as  required,  on  one  or  both  sides  of  the  congenital  fissure. 
The  further  these  horizontal  incisions  are  carried  into  the  cheek  the 
greater  is  the  length  given  to  the  reconstructed  lip.  The  angular 
change  in  the  direction  of  the  vivifying  cuts  should  be  made  at  a  point 
about  three-cparters  the  distance  down  the  lip.  An  incision  around 
the  nasal  ala,  if  it  be  flattened,  and  ample  detachment  of  this  part  of 
the  nose  from  the  underlying  bone  give  opportunity  for  correcting  the 
deformity  of  the  naris  by  one  of  the  methods  to  be  described.  The 
incisions  to  pare  the  edges  of  the  cleft  must  go  well  up  into  the  floor  of 
the  nostril  and  be  placed  far  enough  away  from  the  margins  of  the  cleft 
to  insure  broad  surfaces  of  contact,  when  the  lip  is  sewn. 


Fig.  55. — Method  of  lengthening  the  short  side  of  the  lip  and  correcting  the  flattened  nostril. 


When  the  fissure  is  wide,  it  may  be  well  to  leave  the  parings 
attached  to  the  oral  border  of  the  lip  until  the  freshened  edges  of  the 
cleft  have  been  drawn  together  with  sutures  for  about  two-thirds  of 
their  length.  The  parings  may  then  be  used  to  construct  the  lower 
part  of  the  lip  in  such  a  way  as  to  prevent  the  ugly  notch,  which  is 
sometimes  seen  when  the  tissues  are  scanty.  Usually  it  is  wise  to 
make  the  muco-cutaneous  margin  of  the  lip  pout  a  little,  to  allow  for 
contraction  during  healing.  I  have  used  these  parings  at  times  with 
great  satisfaction,  even  twisting  and  dovetailing  them,  in  order  to  give  a 
long  enough  lip  and  to  avoid  tension  on  the  sutures.  It  is  easy  to  see 
how  much  may  be  cut  away  from  the  ends  of  these  strips  after  the  upper 
parts  of  the  lip  have  been  adjusted  by  the  sutures. 

Instead  of  the  incisions  suggested,  the  margins  of  the  cleft  may  be 
removed  by  two  cuts  made  concave  toward  the  labial  gap.  When 
the  concave  edges  thus  made  are  brought  together,  with  the  stitches, 


HARELIP  AND  OTHER  FACIAL  CLEFTS 


105 


into  a  straight  line,  the  reconstructed  lip  is  caused  to  pout  a  little  at 
its  edge. 

The  sutures  may  be  of  silk,  linen,  worm  gut  or  catgut.  Harelip 
pins  should  never  be  used.  I  always  introduce  the  upper  stitch  first, 
inserting  it  as  a  rule  in  the  groove  outside  of  the  ala.  Two  or  three 
pretty  strong  sutures  are  introduced  and  a  few  finer  ones  are  then 
used  to  adjust  with  accuracy  the  edges  of  skin  and  mucous  membrane. 
The  line  between  skin  and  mucous  membrane  must  accurately  corre- 
spond on  the  two  sides  of  the  suture  line.  The  tension  on  the  stitches 
will  not  be  great,  if  the  lip  has  been  sufficiently  detached  from  the  jaw, 
and  the  incisions  made  so  as  to  give  plenty  of  tissue.  The  stronger 
sutures  may  be  introduced  from,  and  tied  on,  the  mucous  side  of  the 
lip,  without  puncturing  the  skin.  In  this  event  it  is  important  not  to 
evert  the  lip  much  when  these  are  removed,  lest  the  united  wound  be 
torn  apart. 


Fig.  56. — Suture  to  correct  the  flattened  nostril 
after  paring  the  fissure  at  its  base. 


Fig.  57 


-Suture  tightened  by  clamping 
shot  on  the  ends. 


When  the  sutures  are  introduced  from  the  cutaneous  surface  they 
should  not  puncture  the  mucous  membrane,  but  pass  through  the  lip 
just  above  it.  Thus  infection  of  the  suture  track  from  the  fluids  of  the 
mouth  is  less  apt  to  occur.  I  usually  allow  the  edges  of  the  mucous 
membrane  on  the  under  surface  of  the  lip  to  gape  a  little  for  drainage, 
because  it  is  difficult  to  keep  a  wound  so  near  the  nose  and  mouth 
aseptic.  If  the  mucous  membrane  is  not  tightly  stitched,  the  fluids 
from  the  wound  drain  into  the  mouth  and  are  wiped  away  by  the 
patient's  tongue. 

After  the  wound  has  been  sutured  and  cleansed,  a  narrow  strip  of 
sterile  gauze  may  be  laid  over  the  lip  and  held  in  place  against  the 
skin  with  collodion  painted  on  its  ends  only.  It  is  better  to  use  no 
dressing,  or  simply  dust  the  wound  and  the  suture  punctures  with 
boric  acid  or  other  mild  antiseptic  powder.  Dressings  are  apt  to  be- 
come soiled  with  nasal  mucus  and  make  the  suture  holes  septic. 
Small  doses  of  chloral  frequently  repeated  may  be  beneficial  in  keeping 


106  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

the  little  patient  comfortable  and  quiet.  A  dose  of  castor  oil  may  be 
needed  to  get  rid  of  swallowed  blood,  which  sometimes  gives  rise  to 
indigestion.  The  sutures  may  usually  all  be  removed  by  the  end 
of  a  week.  Some  may  be  withdrawn  in  about  four  days.  The 
child's  arms  may  be  kept  semi-extended  at  the  elbow  with  light 
cardboard  splints,  so  that  the  hands  cannot  reach  the  lip  to  disturb 
the  stitches. 

A  satisfactory  adjustment  of  the  flattened  nasal  wing  adds  much 
to  the  cosmetic  effect  of  the  operation.  Sometimes  the  deformity 
is  greater  than  usual,  because  the  nasal  septum  is  turned  over  to  one 
side  and  the  opposite  ala  is  so  flattened  that  the  nostril  becomes  a 
mere  transverse  slit.  As  has  been  mentioned,  the  ala  must  be  freely 
separated  from  the  bone,  so  that  it  may  be  displaced  toward  the  middle 
line.  It  may  be  held  there  until  it  unites,  by  driving  a  needle  through 
it  and  into  the  bone.  Another  method  is  to  thrust  an  acupressure  pin 
horizontally  through  the  displaced  ala,  the  septum  and  the  opposite 
fixed  ala,  and  clamp  a  perforated  shot  on  the  end  of  the  pin,  so  as  to 
maintain  the  desired  position  of  the  ala.  The  skin  should  be  protected 
from  ulcerative  pressure  of  the  head  of  the  pin  and  the  shot  by  means 
of  little  pads  of  rubber  slipped  on  the  pin  next  the  skin.  A  thin  suture 
of  pure  rubber  may  be  used  instead  of  the  pin;  each  end  of  the  trans- 
verse rubber  thread  is  then  clamped  with  a  perforated  shot.  If 
swelling  occurs,  the  rubber  stitch  stretches  and  then  contracts  as  the 
swelling  subsides.  This  form  of  suture  is  not  apt  to  cause  ulceration 
under  the  shot.  A  good  deal  of  improvement  may  be  made  in  the 
appearance  of  the  nose  by  carrying  a  strong  suture  through  the  loosened 
ala,  the  base  of  the  septum  and  the  lip  close  to  the  normal  ala.  This 
suture  is  usually  the  first  one  inserted  by  me  after  vivifying  the  edges 
of  the  labial  gap.  The  stitch  openings  are  in  the  furrows  which  lie 
just  external  to  the  two  wings  of  the  nose.  The  nasal  septum,  if  bent, 
should  be  straightened  when  the  lip  and  the  wing  of  the  nose  are 
operated  upon. 

The  method  of  making  the  incisions  and  repairing  the  lip,  to 
which  Collis'  name  has  been  applied,  is  said  to  make  a  long  lip  and  re- 
construct the  nostril  well.  The  margin  nearer  the  median  line  is 
denuded  by  simply  turning  back  the  mucous  membrane.  The  other 
edge  is  cut  into  two  thick  flaps,  the  upper  of  which  repairs  the  floor 
of  the  nostril  and  the  upper  part  of  the  lip,  while  the  lower  recon- 
structs the  oral  portion  of  the  lip. 

In  very  young  children,  if  both  nostrils  are  temporarily  occluded 
by  the  operation,  it  may  be  wise  to  put  rubber  tubes  in  the  nose  to 
aid  respiration.     It  has  been  said  that  suffocation  may  occur  from 


HARELIP  AND  OTHER  FACIAL  CLEFTS 


107 


neglect  of  this  precaution.  A  satisfactory  preventive  is  to  evert  the 
lower  lip  by  means  of  a  long  suture  put  through  its  mucous  membrane. 
The  suture's  two  ends  should  be  fastened  to  the  chest  with  adhesive 
plaster.  A  wire  retractor  may  be  adjusted  to  the  lower  lip  so  as  to 
keep  it  everted  for  a  day  or  two. 

Secondary  operations  to  perfect  the  cosmetic  result  may  be  done 
when  the  child  has  reached  the  age  of  four  or  five  years,  or  later. 

It  will  be  seen  that  the  modern  operation  for  harelip  has  become 
a  plastic  reconstruction  of  the  lip  and  nostril  instead  of  the  former 
simple  suture  of  two  pared  edges  of  a  fissure.  The  latter  gave  very 
imperfect  cosmetic  results.  A  great  variety  of  methods  of  incising 
the  lip  have  been  proposed.  They  are  perhaps  as  numerous  as  the  sug- 
gestions for  removing  mucous  membrane  in  the  repair  of  ruptured 


Fig.  58. — Diagram  showng  horizontal  incisions  to  permit  sliding  of  tissues  toward  fissure. 
On  patient's  right,  heavj'  line  shows  incision  to  pare  away  one  edge  of  cleft.  On  left  is  showTi 
cut  to  make  a  thick  flap  which  is  to  be  tilted  downward  and  stretched  across  gap.  Relaxation 
cuts  around  alae,  and  sutures  are  shown. 


perineum.  A  wonderful  collection  of  geometrical  figures  have  been 
published  in  describing  each  of  these  operative  procedures.  In  the 
harelip  operation  a  single  effective  method  such  as  that  described 
will  avail  in  nearly  all  cases,  as  is  the  fact  also  in  repairing  a  torn 
pelvic  floor.  The  problem  in  both  instances  is  to  get  broad  masses 
of  muscle  fiber  in  contact,  with  restoration  of  the  proper  contour, 
but  without  tension.  In  wide  clefts  the  incisions  shown  in  figure  58 
may  be  valuable. 

It  is  important  in  harelip  operations  that  no  notch  remain  in  the 
oral  margin  of  the  lip  and  it  is  perhaps  desirable  that  the  main  line 
of  sutures  run  downward  obliquely  on  the  lip,  instead  of  vertically. 
These  two  objects  are  believed  by  some  to  be  obtained  in  unilateral 
clefts  best  by  using  the  structures  of  the  larger  portion  of  the  lip  to 
bridge  the  gap,  and  sacrificing  very  little  tissue  in    obtaining   raw 


108  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

edges.  One  method,  attributed  to  Owen,  consists  in  peeling  or  strip- 
ping the  mucous  membrane  only  from  the  outer  margin  of  the  fissure, 
and  cutting  from  the  median  portion  of  the  lip  a  large  muscular  flap 
with  the  mucosa  intact.  The  mesial  flap  is  then  tilted  downward, 
drawn  across  the  gap  and  sutured  to  the  vivified  opposite  margin. 
In  this  operation  no  tissue  is  removed  except  the  mucous  membrane 
of  one  edge  of  the  cleft.  The  mucosa  of  the  larger  portion  of  the  gap 
becomes  the  vermilion  edge  of  the  reconstructed  lip. 

Double  labial  cleft  is  closed  in  the  same  general  way  as  the  single 
deformity,  but  demands  more  extensive  plastic  work.  The  lip  should 
be  completely  reconstructed  by  closing  both  fissures  at  one  operation. 

Occasionally  the  gap  is  very  wide  with  no  central  piece  of  lip. 
The  intermaxillary  bone  may  be  tilted  out  of  line  or  protrude  greatly 
forward  like  a  proboscis  attached  to  the  nose.  This  bone  is  sometimes 
congenitally  absent.  The  septum  of  the  nose  may  be  bent  or  greatly 
displaced,  or  its  front  portion  may  be  wanting.  Sometimes  the  septum 
between  the  tip  of  the  nose  and  the  lip  is  greatly  shortened.  Not 
infrequently  there  is  an  accompanying  single  or  double  cleft  of  the 
hard  palate  or  perhaps  a  cleft  in  the  alveolus  only,  complicating  the 
deformity  of  the  lip. 

These  deformities  must  be  corrected  in  addition  to  the  repair  of 
the  lip  itself.  Clefts  of  the  hard  palate  should  generally  be  subjected 
to  operation  before  the  gap  in  the  lip  is  sutured.  Alveolar  clefts 
without  fissures  in  the  palatal  processes 'should  be  operated  upon  be- 
fore the  cheilorrhaphy  is  done  to  close  the  gap  in  the  lip.  The  latter 
operation  may  usually  be  undertaken  immediately  after  the  alveolar 
contour  has  been  improved  by  bending,  breaking  or  sawing.  Even 
when  wiring  the  bone  has  been  done,  the  lip  may  be  closed  in  front  of 
the  alveolus  at  once. 

Reconstruction  of  the  upper  lip  in  double  cleft  is  done  by  depriving 
the  central  peninsula  of  its  muco-cutaneous  borders  and  attaching 
the  lateral  portions  of  the  lip  to  these  raw  surfaces.  The  problem 
in  the  condition  is  to  bridge  the  chasm  without  having  too  much  ten- 
sion on  the  tissues.  If  tension  is  great,  the  sutures  will  cut  out;  and 
even  if  they  hold  until  union  occurs  along  the  Y-shaped  suture  line, 
the  tight   flat  upper  lip  will  be  very  disfiguring. 

The  lateral  edges  of  the  double  gap  may  be  pared  and  the  strips  be 
left  attached  below,  as  in  the  first  method  described  above  for  unilateral 
fissure.  By  making  horizontal  cuts  outward  into  the  lip  on  each 
side  of  the  fissure,  raw  margins  may  be  obtained,  which  will  give  the 
repaired  lip  sufficient  height.  Relaxation  incisions  around  one  or 
both  wings  of  the  nose  may  be  made,  if  necessary,  in  order  to  displace 


HARELIP  AND  OTHER  FACIAL  CLEFTS  109 

the  structures  of  the  cheeks  toward  the  middle  line  and  thus  dimin- 
ish the  tension.  If  the  operator  prefer,  cuts  such  as  are  shown  in 
the  second  diagram  may  be  used.  The  turned  down  margins  of  the 
borders  of  the  fissure  in  either  method  are  utilized  wholly  or  partly 
in  the  construction  of  the  lower  or  vermilion  edge  of  the  lip. 

The  inexperienced  or  timid  operator  is  apt  to  restrain  his  knife 
too  much  in  these  reparations.  The  cheeks  will  furnish  sufficient 
musculo-cutaneous  material  free  from  strain,  if  freely  incised  and 
liberated  from  the  underlying  bone.  The  suturing  must  then  be  done 
accurately.  Sometimes  secondary  operations  have  to  be  clone  when 
the  baby  is  three  or  four  years  old  to  remedy  minor  defects  in  the 
reconstruction. 

The  disproportion  between  the  reconstructed  but  flattened  upper 
lip  and  the  relatively  protruding  lower  lip  may  be  remedied  by  ex- 
cising a  V-shaped  piece  from  the  center  of  the  lower  lip  at  the  time  of 
the  original  operation,  if  the  child  will  stand  the  additional  shock. 
It  may  be  better  to  delay  this  procedure  a  few  weeks  if  the  patient  is 
a  very  young  infant.  It  is  possible  to  insert  the  piece  taken  from  the 
lower  lip  into  the  middle  of  the  scanty  upper  lip  at  the  time  of  its 
reconstruction  or  later.  To  do  this  the  excised  section  should  be  cut, 
but  left  attached  at  one  of  its  superior  corners.  It  is  then  turned  on 
this  pedicle  so  that  it  may  be  carefully  adjusted  in  the  space  between 
the  parted  lateral  halves  of  the  defective  upper  lip.  The  bridge  thus 
crossing  the  opening  of  the  mouth  should  not  be  divided  until  about 
ten  clays  later.  Food  can  be  introduced  through  a  corner  of  the 
mouth.  Estlancler,  I  think,  proposed  this  operation.  If  this  sug- 
gestion is  adopted  after  the  double  harelip  has  been  closed,  the  upper 
lip  must  be  split  to  receive  the  flap. 

When  a  harelip,  unilateral  or  bilateral,  is  associated  with  cleft 
of  the  hard  palate  or  of  the  alveolar  process  of  the  jaw,  an  osteoplastic 
operation  should  usually  be  clone  to  bring  together  the  edges  of  the  bonj' 
fissure  under  the  lip,  before  the  labial  cleft  is  closed.  Narrow  fissures 
in  the  alveolus  alone  need  not  be  subjected  to  prior  treatment,  because 
closure  of  the  gap  in  the  lip  will  usually  create  a  support,  and  lead  to 
obliteration  of  the  deficiency  as  dentition  jDrogresses  with  the  increas- 
ing age  of  the  child.  Otherwise  the  separated  portions  of  the  alveolus 
should  be  pressed  together  with  the  fingers  and  wired.  Section  of  the 
semi-cartilaginous  or  bony  jaw  may  be  required,  with  tenotome, 
saw  or  chisel,  to  enable  the  surgeon  to  properh'  adjust  the  two  seg- 
ments. These  may  originally  be  quite  out  of  line  and  even  in  different 
planes.  The  section  and  the  drill  holes  should,  as  far  as  possible, 
be  between  the  points  where  the  teeth  germs  lie  in  the  bone.     The 


110  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

details  of  this  procedure  will  be  described  more  at  length  when  the 
treatment  of  cleft  palate  is  discussed. 

If  the  septum  of  the  nose  is  deflected  or  the  whole  nose  is  the  seat  of 
lateral  deviation  in  association  with  the  deformity  of  the  lip,  the 
surgeon  should  endeavor  so  far  as  possible  to  correct  this  deformity, 
when  he  operates  on  the  lip.  In  very  young  babies,  however,  it  may 
be  unwise  to  do  more  than  make  a  fairly  good  closure  of  the  lip  as  a 
primary  operation. 

A  deflected  septum  may  be  twisted  or  bent  into  place  with  flat  blade 
forceps  or  subjected  to  incision  or  fracture  for  that  purpose.  Thin 
nails  or  needles,  used  as  nails,  may  be  driven  into  the  jaw  bone  through 
the  soft  tissues  of  the  lip  or  nose  to  hold  the  septum,  the  nasal  lobule  or 
the  ala  in  a  corrected  position. 

The  mal-placed  intermaxillary  bone  hanging  from  the  end  of  the 
nose  or  projecting  between  the  lateral  halves  of  the  superior  maxilla 
must  be  treated  surgically  before  the  gap  in  the  lip  is  closed.  If  it 
cannot  be  pressed  downward  and  backward,  with  or  without  fracture, 
so  as  to  fill  the  alveolar  cleft  and  thus  complete  the  arch,  a  triangular 
piece  of  the  septum  should  be  cut  out  with  scissors  or  cutting  forceps, 
just  behind  the  protrusion.  This  may  be  done  without  much  bleeding 
by  making  an  antero-posterior  cut  through  the  mucous  membrane 
on  the  lower  edge  of  the  septum  and  detaching  the  muco-periosteal 
tissues  on  each  side  with  an  elevator.  The  subperiosteal  excision  of 
this  V-shaped  portion  with  its  apex  upward  will  make  it  easy  to  shove 
the  projecting  intermaxilla  backward.  It  may  or  may  not  be 
wired  to  the  adjacent  margins  of  the  alveolus.  The  abutting  borders 
of  the  alveolar  segments  need  not  be  freshened,  since  union  will  take 
place  finally  without  that  procedure;  though  there  is  no  objection  to 
shaving  off  the  mucosa.  In  some  instances  instead  of  excising  the 
V-piece,  the  operator  may  detach  the  muco-periosteum  on  both  sides, 
split  the  septum  by  a  vertical  cut  and  by  pressure  slide  the  front  portion 
past  the  back  portion  of  the  septum.  Sometimes  a  horizontal  cut 
across  the  front  of  the  projecting  bone  will  be  sufficient  to  make  its  re- 
placement possible. 

It  is  probably  unwise  in  the  great  m'^jority  of  cases  to  remove  the 
intermaxillary  bone.  It  has  been  proposed  to  scoop  out  the  bony 
tissue  and  leave  the  periosteum.  Usually  the  bone  can  be  utilized 
more  or  less  satisfactorily  by  replacing  it  between  the  lateral  alveolar 
segments.  A  very  rare  complication  of  harelip  is  an  associated  cleft 
in  the  face  extending  upward  toward  the  eye. 

Instead  of  closing  the  double  harelip  cleft  in  the  manner  described 
above,  an  operation  similar  to  that  attributed  to  Owen  for  unilateral 


HARELIP  AND  OTHER  FACIAL  CLEFTS  111 

fissure  may  be  used.  In  it  the  mucosa  is  peeled  from  the  smaller  lateral 
segment  and  the  margins  of  the  central  bud.  The  larger  lateral  segment 
has  a  thick  flap  made  from  it  by  an  incision  running  downward  and  out- 
ward from  the  nostril.  This  flap  is  displaced  downward  and  dovetailed 
with  a  similar  flap  made  from  the  smaller  margin  of  the  cleft,  so  as  to 
close  the  gap  and  make  at  the  same  time  the  lower  border  of  the  new 

Another  means  of  reconstructing  the  lip  in  double  cleft,  with 
great  scarcity  of  labial  tissues,  is  to  make  an  incision  around  the 
wing  of  the  nose  on  each  side  and  continue  it  outward  and  downward 
in  the  cheek  itself.  This  enables  the  operator  to  displace  two  thick 
flaps  from  the  cheeks  downward  and  inward  toward  the  median  bud 
under  the  nose  to  which  they  are  sutured.  The  gaps  left  in  the 
cheeks  are  closed  with  sutures  applied  across  the  two  angles  of  the 
openings. 

Another  satisfactory  operation  is  that  based  on  incisions  similar 
to  those  used  in  the  method  called  Collis  for  closing  single  harelip. 


CHAPTER  X. 
CLEFT  PALATE. 

Congenital  fissure  of  the  bony  and  muscular  partition  between  the 
nose  and  mouth,  called  cleft  palate,  is  so  often  an  accompaniment  of 
harelip  that  it  is  desirable  to  discuss  this  defect  here  in  connection 
with  the  surgery  of  harelip.  The  plastic  restorations  of  the  lips 
other  than  that  for  harelip  will  be  described  later. 

Congenital  gaps  in  the  upper  lip  and  in  the  roof  of  the  mouth 
are  the  results  of  imperfect  closure  in  the  embryo  of  the  notches 
between  the  maxillary  buds  at  the  sides  of  the  head  and  the  fronto- 
nasal bud,  which  comes  down  from  above  in  the  middle  line.  If 
union  is  deficient  posteriorly,  there  is  a  palatine  gap,  if  in  front,  a 
labial  fissure  remains.  When  the  defect  occurs  in  the  back  part  of 
the  palate,  the  fissure  is  median,  because  the  two  embryonic  palatine 
processes  come  together  there  in  the  middle  line  of  the  body.  In  the 
front  part  of  the  palate  the  clefts  run  outward  toward  the  interval 
between  the  central  and  lateral  incisor  teeth.  The  location  of  the 
fissures  in  cases  of  harelip  accords  with  that  of  the  gaps  in  the  anterior 
portion  of  the  hard  palate.  This  circumstance  has  been  mentioned  in 
considering  harelip. 

When  the  frontal  bud  of  the  embryo  does  not  unite  with  the 
maxillary  buds  laterally  and  develops  forward  abnormally,  it  de- 
velops into  the  protuberance  attached  to  the  nose,  to  which  reference 
has  been  made  in  the  section  on  harelip.  The  two  central  incisors  are 
contained  in  this  intermaxillary  segment  of  the  alveolus  and  hard 
palate.  As  the  infant  becomes  older  the  cleft  in  the  alveolus,  if  un- 
treated may  narrow  perhaps  and  thrust  the  intermaxillary  bone  further 
forward. 

The  cleft  in  the  palate  may  be  so  incomplete  as  to  be  merely  a 
bifid  condition  of  the  uvula.  This  needs  no  treatment,  except  as 
a  cosmetic  procedure.  The  edges  of  the  fissure  may  be  pared  with  a 
thin  knife,  such  as  is  used  for  the  corneal  incision  in  cataract  extraction, 
and  the  two  halves  of  the  uvula  be  brought  together  with  thin  silk 
or  linen  thread.  A  similar  means  may  be  employed,  if  the  fissure  ex- 
tends forward  toward  the  hard  palate  for  a  short  distance. 

112 


CLEFT  PALATE  ILS 

When  this  gap  in  the  pendulous  muscular  palate  reaches  to,  or 
almost  to,  the  posterior  edge  of  the  bony  palate,  the  operation  must 
be  a  more  extensive  one.  It  should  include  detaching  freely  the  soft 
palate  from  the  posterior  edge,  and  also  from  a  considerabe  portion  of 
the  oral  aspect,  of  the  bony  palate.  This  detachment  frees  the  soft 
palate,  so  that  it  falls  downward  toward  the  tongue.  As  a  result 
injurious  tension  on  the  stitches  is  prevented  and  the  sutures  used  to 
obtain  apposition  of  the  two  lateral  halves  of  the  pendulous  palate  do 
not  cut  through  the  tissues.  The  impossibility  of  obtaining  asepsis 
of  the  field,  during  or  after  cleft  palate  operations,  makes  the  pres- 
ence of  marked  tension  on  the  flaps  prohibitive  of  success. 

Fissure  of  the  hard  palate  occasionally  exists  as  a  mere  want  of 
union  between  the  two  sides  of  the  bony  roof  of  the  mouth  without 
any  corresponding  breach  in  the  mucous  covering.  No  opening  be- 
tween mouth  and  nose  occurs  therefore  through  the  palate,  but  when 
the  patient  takes  a  deep  inspiration  with  the  mouth  open,  the  ob- 
server will  see  a  longitudinal  furrow  develop  in  the  middle  of  the  roof 
of  the  mouth.  This  is  caused  by  the  pressure  of  the  air  forcing  the 
mucous  membrane  into  the  groove  in  the  underlying  bony  partition. 
Such  cases  need  no  treatment. 

Reference  has  already  been  made  to  the  occurrence  of  clefts  in  the 
alveolar  process  of  the  upper  jaw  often  associated  with  harelip.  Al- 
veolar fissure  may  occur  also  with  cleft  in  the  palate  with  or  without 
cleft  in  the  lip.  Sometimes  the  alveolus  alone  is  cleft;  it  may  show 
merely  an  irregularity  as  if  a  narrow  fissure  had  previously  existed. 
When  the  hard  palate  is  open,  the  fissure  divides  usually  the  soft 
palate  as  well,  unless  the  division  in  the  bone  involves  only  the  alveo- 
lus and  the  part  of  the  palate  immediately  behind  it.  The  gap  in  the 
soft  and  hard  palate  may  be  narrow  or  wide  and  may  stop  at  any 
point  in  the  length  of  the  mouth's  roof.  The  central  portion  may 
be  closed  and  a  fissure  exist  only  in  the  alveolus  in  front  and  the  soft 
pendulous  palate  behind. 

The  congenital  fissure  of  the  palate,  which  is  the  bugbear  of  sur- 
geons, is  a  complete  communication  from  the  tip  of  the  uvula  to  and 
including  the  upper  lip  through  the  partition  separating  mouth  from 
nose.  It  involves  the  muco-periosteal  coverings  on  the  oral  and 
nasalsicles  of  the  palatine  processes  of  the  jaw  and  palate  bones  as 
well  as  the  intervening  osseous  structures.  The  fissure  maybe  single 
or  double.  The  vomer  may  be  bent  and  attached  to  one  or  other 
side  of  the  gap,  be  only  partially  developed,  or  even  entirely  absent. 
In  such  complete  clefts  of  the  upper  lip,  the  alveolus  and  the  hard  and 
soft  palate,  when  double,  the  mouth  and  nose  of  the  infant  form  one 

8 


114  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

irregular  chasm  without  any  intervening  partition.  Two  small 
lateral  ledges  represent  the  palatine  processes.  It  should  be  remem- 
bered that  posteriorly  the  palatal  cleft  is  always  single  and  median; 
anteriorly  it  may  be  double  if  there  is  non-union  of  the  intermaxilla 
with  the  maxilla  of  each  side.  The  vomer,  if  not  deficient,  often 
makes  the  anterior  palatal  cleft  single  by  being  united  to  one  or  other 
palatal  process. 

Practically  all  of  these  cases  of  cleft  palate  should  be  treated  by 
operation,  for  obturators,  the  so-called  artificial  palate  with  movable 
velum,  are  less  satisfactory  than  a  palate  closed  by  the  surgeon. 
Within  recent  years  the  operative  treatment  of  this  deformity  has 
been  greatly  improved.  In  the  hands  of  experienced  operators  a 
great  deal  of  benefit  can  be  obtained  for  the  unfortunate  child,  but 
the  period  of  treatment  must  extend  through  months,  since  a  com- 
plete reconstruction  of  the  roof  of  the  mouth  may  require  a  series  of 
operations.  Later  the  patient  must  be  taught  by  an  expert  to  use 
the  organs  of  speech  efficiently.  The  child  with  a  cleft  palate  should 
not  be  permitted  to  grow  up  with  the  fissure  between  mouth  and  nose 
remaining  open. 

The  treatment  should  begin  on  the  day  of  the  child's  birth  by  the 
nurse  endeavoring  to  drive  the  two  halves  of  the  open  hard  palate 
together  by  gentle  but  firm  pressure  with  the  fingers  applied  through 
the  cheeks.  It  is  probable  that  usually  there  is  no  actual  loss  of  bone 
but  a  want  of  mesial  union.  Clefts  in  the  soft  palate  alone  do  not 
need  and  would  not  be  benefited  by  this  maneuver.  Such  fissures 
may  be  permitted  to  wait  for  treatment  for  several  months  without 
any  real  disadvantage.  Separations  of  the  hard  palate,  however, 
may  if  untreated,  become  wider  because  of  the  sucking  action  of  the 
child  and  the  wedge-like  action  of  the  mandible,  when  the  mouth  is 
closed. 

Dr.  L.  J.  Hammond  of  Philadelphia  has  devised  a  clamp  for  pres- 
sing the  maxillary  segments  toward  the  middle  line.  This  may  be 
tightened  daily  and  has,  he  thinks,  been  effective.  It  has  teeth, 
which  are  engaged  in  the  buccal  surface  of  the  alveolar  process  on 
each  side  of  the  fissure.  I  have  used  a  modification  of  his  clamp, 
which  I  had  made;  but  am  not  yet  satisfied  with  its  action.  I  had  the 
teeth  placed  on  the  upper  edge  of  the  clamp  so  that  they  could  be 
thrust  into  the  jaw  above  the  cartilaginous  alveolus.  I  then  dis- 
sected the  cheek  from  the  jaw  on  each  side  before  applying  the  clamp. 
This  change  seemed  demanded,  because  otherwise  the  pressure  was 
only  upon  the  alveolus,  which  was  bent  toward  the  middle  line 
without  carrying  the  body  of  the  bone  with  it.     It  will  be  necessary, 


CLEFT  PALATE 


115 


I  think,  to  have  the  teeth  project  like  hooks  above  the  upper  edge  of 
the  clamp,  with  their  points  bent  inward. 

The  clamp  is  quickly  applied.  The  little  operation  takes  but  a 
few  moments,  including  the  time  to  cut  loose  the  cheek  from  jaw 
within  the  mouth,  in  order  to  insert  the  clamp's  teeth  high  enough  on 
the  bone.  A  few  whiffs  of  ether  will  be  sufficient  for  the  anesthesia. 
The  mouth  should  be  washed  several  times  daily  with  a  mild  anti- 
septic solution,  such  as  five  grains  of  boric  acid  to  the  fluid  ounce  of 


Fig.  59. — Roberts's  modification  of  Hammond's  eleft-palate  clamp. 


water,  or  compound  solution  of  sodium  borate  diluted  with  one  or 
two  parts  of  water.  The  clamp  is  tightened  a  little  every  day  as  the 
two  segments  of  bone  come  nearer  and  nearer  together.  The  roof 
of  the  mouth  is  finally  repaired  with  sutures.  Theoretically  the 
method  is  valuable;  but  its  practical  usefulness  has  not  yet  been 
established.  Young  children  in  whom  the  teeth  have  already  ap- 
peared might  perhaps  be  benefited  by  caps,  cemented  to  the  molar 
teeth,  being  drawn  gradually  toward  each  other  by  a  screw. 


116 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


A  more  elaborate  and  a  better  method  is  that  of  Brophy.  He 
draws  the  semi-cartilaginous  sides  of  the  cleft  together  with  wire 
sutures  carried  through  the  maxihary  and  palate  bones  above  the 
alveolus,  making  of  the  wires  what  may  be  called  the  ''tie-beams" 
of  the  arched  roof  of  the  mouth.  This  operation  is  available  only 
during  the  first  four  or  five  months  of  life,  before  the  bones  become  too 


Fig.  60. — Roberts's  cleft-palate  clamp  applied. 


rigid  by  progressive  ossification.  It  should  be  undertaken  as  soon 
after  birth  as  possible.  The  shock  is  slight  and  the  hemorrhage  un- 
important. After  the  sixth  month  of  life  this  operation  is  said  to  be 
impossible.  It  is  difficult  of  accomplishment  even  at  a  somewhat 
earlier  age,  when  it  may  be  necessary  to  make  a  green-stick  fracture 
of  the  jaw  near  its  malar  junction  or  to  divide  the  bone  with  a  chisel 
or  strong  knife. 


("LEFT  PALATE 


117 


The  view  that  operations  on  fissures  of  the  palate  should  be  de-. 
layed  until  the  child  has  become  two,  three,  or  four  years  old  is  erro- 
neous. It  is  better  to  operate  when  the  infant  is  only  a  few  days  old, 
unless  there  be  some  very  grave  physical  debility.  In  that  event  the 
operation  may  be  delayed  a  few  weeks,  but  such  delay  is  a  misfortune. 
The  time  thus  occupied  in  building  up  the  infant's  health  may  be 
profitably  employed  in  digital  compression,  applied  daily  to  the  two 
halves  of  the  upper  jaw.  Squeezing  the  separated  segments  of  the 
hard  palate  together  a  few  times  every  morning  and  evening  will 
tend  to  lessen  the  breadth  of  the  cleft  and  give  the  surgeon  a  better 
opportunity  of  obtaining  a  bony  roof  to  the  mouth  by  operation. 

In  the  osteoplastic  method  of  Brophy  just  mentioned  the  surgeon 
by  means  of  long  needles,  carries  strong  wires  through  the  two  upper 


Fig.  61. — Brophy's  needle  for  introducing  wire  "tie  beams." 


maxillary  bones  above  the  level  of  the  palate.  The  ends  of  these 
wires  are  passed  through  holes  in  leaden  plates,  placed  on  the  external, 
or  buccal,  surface  of  the  bones.  After  the  two  parts  of  the  hard  palate 
have  been  forced  as  near  together  as  possible,  by  the  surgeon's  fingers, 
the  adjoining  ends  of  wire  are  twisted  and  the  bones  thus  held  in  the 
new  position.  Gradually  increasing  pressure  is  made  at  intervals  and 
is  maintained  by  slowly  twisting  the  wires  alternately  more  and  more, 
thus  finally  bringing  the  bones  in  contact. 

This  procedure  causes  the  loss  of  but  a  few  drops  of  blood,  gives 
rise  to  little  or  no  surgical  shock  or  pain,  and  has  the  inestimable 
advantage  of  restoring  wholly  or  in  part  the  normal  width  of  the 
defectively  united  roof  of  the  mouth.  Even  if  the  two  upper  maxil- 
lary bones  cannot  be  brought  absolutely  together  much  is  gained  by 
diminishing  the  width  of  the  cleft  in  the  upper  jaw.  If  restoration 
of  the  oral  roof  is  not  done  thus  early,  the  sucking  and  chewing  of  the 
babe  and  future  child  perhaps  tend  during  the  first  years  of  life  to 
increase  the  width  of  the  palatal  fissure.  After  the  use  of  the  wire 
tie-beams,  as  they  may  be  called,  for  about  eight  weeks,  muco-perios- 
teal  flaps  from  the  oral  surface  of  the  palate  may  be  used  to  close  any 
remaining  gap  in  the  hard  palate.  The  soft  palate  may  then  be  closed 
by  freshening  and  suturing  its  edges,  which  now  lie  comparatively, 
close  together,  or  by  using  flaps  of  mucocellular  tissue,  as  in  Lane's^; 


118 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


operation.  In  narrow  clefts  the  sof.t  palate  may  be  sutured  at  the 
time  the  wires  are  introduced  to  bring  the  two  halves  of  the  bony- 
palate  together. 

In  babies  too  old  to  permit  the  desired   displacement  inward  of 


Fig.  62. — Diagram  of  palate  in  Brophy's  osteoplastic  operation. 

the  partly  ossified  bones  coaptation  sometimes  may  be  accomplished 
by  dividing  the  jaw  with  chisel  or  saw  above  the  level  of  the  tie-beams. 
This  renders  more  grave  an  operation,  which  is  in  recently  born  infants 
quite  safe.     The  bleeding  is  greater,  the  shock  more  marked.     The 


Fig.  63. — Diagram  of  coronal  section  of  Brophy's  method.    A,  jaw;  O,  orbit;  V,  vomer;  H,  antrum; 
P,  palate;  T,  tooth;  B,  lead  plate. 

older  infant  moreover  is  probably  more  sensitive  to  nervous  impres- 
sions, such  as  shock  and  pain,  than  the  newborn  child. 

If  the  golden  opportunity  for  operating  on  these  unfortunate  chil- 
dren has  been  lost  by  unwise  or  unpreventable  delay,  one  of  the  more 
formal  operative  procedures  should  be  adopted. 


CLEFT  PALATE 


119 


One  should  rarely  be  tempted  to  operate  on  the  harelip,  if  this 
coexist,  before  treating  by  operation  the  palatal  deficiency.  It  was 
formerly  a  common  practice  to  correct  the  labial  deformity  early  in 
infancy,  and  postpone  the  operation  on  the  roof  of  the  mouth  for 
several  years.  This  is  an  error.  The  great  improvement  in  the 
physical  appearance  of  the  child  resulting  from  the  closure  of  the 
harelip  is  admitted.  It  is  much  more  important,  however,  to  close 
the  roof  of  the  mouth  as  soon  after  birth  as  possible,  in  order  that 
the  nasopharynx  and  accessory  sinuses  of  the  nose  may  be  developed 
by  the  pressure  of  inspired  air.  The  whole  facial  appearance  of  a 
growing  child  is  changed  by  the  direct  and  indirect  influence  of  this 
conversion  of  a  mouth  breather  into  a  nose  breather.     An  additional 


Fig.  64. — Rupert's  etherizing  apparatus. 


result  may  be  expected  from  closing  the  opening  in  the  oronasal  par- 
tition of  the  baby.  It  is  the  avoidance,  to  a  great  extent  at  least,  of  the 
catarrhal  rhinitis  and  pharyngitis  so  common  in  cleft  palate  patients. 

Closure  of  the  lip  does  not  effect  these  desirable  improvements  in 
the  child's  health  and  facial  contour;  and,  if  done  before  the  palate 
operation,  it  is  in  a  sense  detrimental,  because  it  interferes  somewhat 
with  the  necessary  uranoplastic  manipulations  by  lessening  the  ease 
of  approach  to  the  operative  field. 

General  anesthesia  should  always  be  employed,  because  it  lessens 
shock,  the  operation  is  necessarily  protracted,  and  the  omission  of 
anesthesia  savors  of  cruelty.  Chloroform  is  more  satisfactory  than 
ether,  because  it  does  not  give  rise  to  so  great  a  secretion  of  mucus 
in  the  throat.     Because  of  its  greater  danger  than  ether,  I  usually 


120  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

have  the  child  anesthetized  with  ether  and  continue  with  chloroform. 
The  most  convenient  method  of  administering  the  chloroform  is  by 
means  of  an  apparatus,  which  permits  its  vapor  to  be  pumped  slowly 
into  the  nose  or  mouth  through  a  tube.  The  anesthetization  must  be 
under  the  care  of  an  expert  administrator  lest  death  from  chloroform 
or  pneumonia  from  ether  be  the  result. 

It  is  best  to  operate  upon  the  alveolar  process  and  palate  before 
closing  the  lip.  If  this  choice  is  not  possible,  it  may  at  times  be 
permissible  to  close  the  lip  before  the  surgeon  undertakes  to  close  the 
roof  of  the  mouth.  There  is  little  doubt  that  the  tension  made  upon 
the  bones  at  the  front  of  the  mouth  by  a  united  lip  tends  to  encourage 
closure  of  the  front  part  of  the  palatal  fissure.  In  any  event  it  pre- 
vents an  increase  of  the  width  of  the  gap.  Imperative  reasons  for 
closing  the  lip  before  treating  the  cleft  in  the  mouth  may  be  obeyed. 
Subsequently  the  lip  may  be  incised,  if  necessary,  to  furnish  satis- 
factory access  for  the  palatal  manipulations. 

It  often  happens  that  complicated  cases  of  cleft  in  the  lip  and 
palate  show  an  imperfect  alignment  of  the  alveolar  process  at  the 
point  where  the  cleft  or  clefts  occur.  In  double  cleft  of  the  palate 
the  intermaxillary  portion  may  project  far  forward  and  be  attached 
near  to  the  tip  of  the  nose  because  of  .the  short  septum.  In  single 
clefts  the  alveolus  on  one  side  may  be  so  out  of  line  that  when  the  two 
portions  are  brought  together  one  end  will  overlap  the  other.  It  is 
necessary  in  these  cases  to  correct  the  irregular  position  of  the  alveolar 
process  in  order  to  make  a"  symmetrical  arch  in  front.  This  should 
be  done  either  before  or  at  the  same  time  that  the  attempt  is  made 
to  close  the  gap  in  the  palate  posteriorly.  If  for  any  reason  the 
surgeon  decides  to  close  the  lip  before  he  closes  the  palate,  the  alveolus 
must  be  reconstructed  before  the  lip  is  sutured.  In  other  words, 
whichever  plan  the  surgeon  adopts,  an  osteoplastic  operation  is  the 
first  step. 

Reconstruction  of  the  arch  is  effected  by  dividing  the  alveolar 
process  submucously  with  a  narrow  knife  or  tenotome,  at  a  point  far 
enough  from  the  middle  line  to  enable  the  surgeon  to  bend  the  alveolar 
process  in  the  proper  direction.  This  closes,  more  or  less  completely, 
the  gap  in  the  arch.  The  soft  bone  is  to  be  held  in  the  new  position 
by  a  suture  of  silver  or  other  flexible  wire.  This  is  applied  as  a  mat- 
tress suture  through  the  structures  of  the  undisturbed  alveolus  and 
the  portion  which  has  been  replaced.  If  the  fissure  in  the  palate  and 
alveolus  is  double  this  mattress  suture  may  be  carried  in  front  of  the 
median  portion  of  the  arch  to  hold  it  back  by  pressure,  without  per- 
forating it.     The  bone  is  to  be  cut  submucously  and  the  mattress 


CLEFT  PALATE  121 

sutures  introduced  in  such  a  situation  as  will  cause  the  least  injury 
to  the  tooth  germs.  A  narrow  saw  may  be  required  to  divide  the 
alveolus. 

Sometimes  not  only  the  alveolus  but  the  adjoining  portion  of 
the  anterior  palate  must  be  moved  toward  the  median  line  after  an 
oblique  section  through  the  intermaxillary  bone  or  the  maxilla,  ex- 
tending from  the  buccal  surface  of  the  alveolus  to  the  palatine  cleft. 
The  fragment,  which  should  be  detached  from  the  more  eligible  side 
of  the  gap,  should  be  wired  in  the  desired  position.  The  fissures  left 
after  the  loosened  piece  has  been  prized  over  are  allowed  to  close  by 
nature's  efforts.  I  have  usually  detached  a  piece  from  each  side  of  the 
gap  and  wired  them  together  in  the  median  line. 

If  the  intermaxillary  bone  projects  markedly,  it  will  be  necessary 
to  do  some  form  of  plastic  operation  upon  the  vomer  and  septal 


Fig.  65. — Diagram  of  suture  through  Fig.  66. — Diagram  of  suture  twisted 

alveolus  to  obtain  ahgnment.  after  di^'iding  or  breaking  bone. 

cartilage  of  the  nose,  in  order  to  thrust  the  intermaxillary  portion 
backward  and  bring  it  downward.  These  procedures  have  been 
discussed  when  describing  operations  for  the  cleft  of  the  lip.  The 
sutures  maintaining  the  segments  of  the  alveolar  arch  in  the  new 
position  may  be  allowed  to  remain  from  twelve  to  sixteen  days  or 
even  longer,  if  they  cause  no  special  irritation.  During  this  period, 
work  may  be  done  upon  the  lateral  portions  of  the  jaw  to  close  the 
gap  in  the  palate. 

In  nearly  all  these  cases  of  complicated  harelip  and  cleft  palate, 
plastic  procedures  are  required  to  improve  the  appearance  of  the 
nostrils.  Operations  to  relieve  this  condition  are  described  in  the 
section  on  harelip.  Other  nasal  deformities  associated  with  con- 
genital defects  may  be  repaired  by  operations  described  in  the  section 
on  rhinoplasty.  The  unsightly  condition  of  the  nose  before  or  after 
the  harelip  operation  may  be  due  to  a  deviation  of  the  septum,  not 
corrected  at  the  time  the  lip  was  closed,  to  absence  or  sinking  of  the 


122 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


floor  of  the  nostril,  or  to  an  improper  position  of  the  ala.  Free  separa- 
tion of  the  tissues  of  the  nose,  from  their  attachment  to  the  upper 
jaw,  may  be  made  within  the  mouth  under  the  upper  lip  without 
making  any  external  scar.  This  is  often  the  best  mode  of  approach 
to  the  structures  in  malposition. 

The  nostril  on  the  side  of  the  congenital  fissure  is  nearly  always 
broadened  and  the  ala  flattened.  In  the  simpler  cases  of  this  defor- 
mity, a  wire  suture  carried  from  the  groove  on  the  outside  of  the  ala, 
deeply  through  the  structures  at  the  floor  of  the  nostril  and  through 
the  septal  cartilage  to  the  opposite  nostril,  will  often  suffice  to  narrow 
the  nostril  and  relieve  the  flattening  of  the  ala.     Such  a  suture  may 


0r' 


Fig.  67. — Diagram  of  Duplay's  method  of  changing  position  of  alveolar  gap. 

be  secured  by  shot  on  each  end.  More  elaborate  plastic  procedures 
are  sometimes  required  to  improve  the  appearance  of  the  nostrils 
and  septum. 

The  flat  nose  occasionally  found  in  double  harelip,  due  to  a  short 
septum  and  columella,  may  require  lengthening  of  the  septum  by  a 
V-shaped  incision  into  the  tissues  of  the  lip  with  appropriate  suturing. 

When  a  cleft  palate  involving  the  bony  portion  of  the  roof  of  the 
mouth  is  to  be  treated  in  a  child,  who  is  over  say  five  or  six  months  of 
age,  or  in  an  adolescent  or  an  adult,  one  of  the  muco-periosteal 
flap  methods  must  be  used.  In  a  narrow  and  short  cleft  of  the  soft 
palate  simple  approximation  of  the  pared  edges  with  sutures,  including 
usually  about  one-third  or  one-half  inch  of  tissue  on  each  side  of  the 
fissure  will  usually  be  satisfactory.  Wider  clefts  will  demand  a  flap 
operation,  as  will  also  narrow  clefts,  if  they  extend  up  to  or  into  the 
hard  palate. 

Before  undertaking  these  serious  and  troublesome  plastic  repara- 


CLEFT  PALATE  123 

tions  the  patient  should  be  brought  into  a  fair  condition  of  general 
health,  if  there  is  evident  more  deterioration  than  can  be  attributed 
to  the  deformity.  Good  food  and  tonics  may  be  needed.  Infants 
can  at  times  be  nourished  satisfactorily  by  using  a  large  soft  rubber 
nipple,  Avith  a  perforation  on  its  lower  surface,  on  the  milk  bottle. 
The  patient's  mouth,  nose  and  pharynx  should  be  prepared  in  an 
effort  to  avoid  any  unnecessary  source  of  infection.  Cleansing  the 
teeth  thoroughly  and  spraying  the  nose  and  throat  with  antiseptic 
and  astringent  solutions  for  several  days  before  operation  are  wise 
precautions.  The  teeth  of  older  subjects  may  be  subjected  to  a 
thorough  cleansing  and  polishing  by  a  dentist.  Inflammation  of 
the  mucous  membrane  and  the  glands  should  be  cured  or  abated. 
Suppurative  processes  about  the  tonsils  and  teeth  and  in  the  middle 
ear  should  be  stopped,  if  practicable.  Inflammation  and  hyper- 
trophy of  the  pharyngeal  tonsil  should  probably  be  removed.  Ex- 
cessive hypertrophy  of  the  faucial  tonsils  should  be  treated  by  re- 
moval of  the  prominent  portion  of  the  chronically  enlarged  glands. 
The  entire  tonsil  need  not  be  removed.  In  fact,  the  present  zeal  for 
extirpation  of  the  entire  tonsil  in  children  is,  I  believe,  a  surgical  and 
probably  a  physiological  error;  even  if  hypertrophy  and  recurrent  irri- 
tation is  present.  Excision  of  the  portion  of  the  gland  projecting  into 
the  fauces  and  obstructing  respiration  is  sufficient  in  my  opinion  in  a 
great  majority  of  the  cases.  If  the  entire  pharyngeal  tonsil,  the  so- 
called  adenoid  growths  in  the  pharynx  are  scraped  away,  care  should 
be  observed  not  to  do  much  damage  to  the  mucosa  of  the  wall. 

After  the  wounds  in  the  throat  have  healed,  if  tonsils  or  adenoids 
have  been  operated  upon,  and  the  mucous  membrane  has  been  rendered 
relatively  healthy,  the  patient  should  be  prepared  for  anesthesia  in  the 
usual  manner.  I  usually  operate  with  him  lying  supine  and  having 
a  small  cylindrical  roll  or  pillow  under  the  nape  of  the  neck,  so  as  to 
throw  the  head  well  back.  The  blood  is  then  not  very  likely  to  get 
into  the  larynx  or  trachea,  if  the  assistants  frequently  mop  out  the 
throat  with  pieces  of  sterile  sea  sponge  firmly  held  in  locked  long  for- 
ceps. A  good  gag  acting  upon  the  incisor  teeth  or  holding  the  jaws 
apart  by  separating  the  upper  and  lower  molars  is  an  essential.  It 
is  a  convenience  to  keep  the  tongue  drawn  out  of  the  mouth  by  means 
of  a  long  suture  thread  carried  through  it  near  the  tip  with  a  fairly 
large  needle.  At  the  end  of  the  operation  the  string  is  removed  from 
the  tongue.  The  small  puncture  made  for  the  passage  of  the  string 
is  unimportant  and  gives  the  patient  little  subsequent  annoyance. 
Some  gags  control  the  tongue  sufficiently  well  without  the  aid  of  this 
traction  cord. 


124  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

In  all  flap  operations  it  is  necessary  to  have  enough  tissue  to  avoid 
tension  on  the  sutures  when  the  gap  is  bridged.  One  must  take  suffi- 
cient tissue  in  the  grasp  of  the  sutures  to  prevent  the  sutures  cutting 
through  the  edge  of  the  flaps  before  strong  union  occurs.  Neglect 
of  this  precaution  is  a  frequent  cause  of  failure. 

Suture  material  may  be  wire,  silk,  silkworm  gut,  catgut,  horsehair, 
or  Pagenstecher  linen  thread.  It  is  probable  that  silkworm  gut, 
silver  wire,  and  Pagenstecher  thread  are  the  best.  Tension  sutures 
to  lessen  the  strain  on  the  coaptation  sutures  are  quite  essential. 


SfttryvcTin^ 


Fig.  68. — Diagram  of  Duplay's  method  of  changing  site  of  alveolar  gap,  showing  fragment  wired 

in  new  position. 


The  coaptation  sutures  may  be  applied  as  mattress  sutures.     This 
has  been  recommended  by  Sherman.     A  wide  surface  of  apposition 
is  obtained  by  using  this  method  and  the  sutures  are  less  apt  to  cut' 
out  when  the  stitch  tracks  become  infected.     Lead  plates  or  buttons 
may  be  used  on  the  tension  sutures  to  distribute  the  pressure. 

When  the  arch  of  the  palate  is  low,  I  am  rather  inclined  to  prefer 
the  flaps  used  by  Lane.  In  a  very  high  arch  the  separation  of  the 
flaps  from  the  edge  of  the  cleft  outward  toward  the  teeth,  without 
incision  near  the  alveolus,  will  usually  be  satisfactory.  This  is  the 
operation  usually  performed  by  Brophy  in  patients  older  than  six 
months.  The  height  of  the  arch  permits  the  cutting  of  flaps  large 
enough  to  give  apposition  in  the  middle  line  without  grave  tension. 
The  soft  palate  must  be  cut  completely  free  from  the  posterior  edge 
of  the  bony  palate.  This  permits  the  soft  parts  to  drop  downward. 
When  the  arch  is  not  high,  I  think  that  the  Lane  flaps  are  better  than 
flaps  made   according  to  the  older  procedure  recommended  by  Sir 


CLEFT  PALATE 


125 


William  Fergusson  or  that  just  discussed,  as  the  method  preferred 
by  Brophy. 

Lane  makes  a  crescentic  antero-posterior  incision  on  the  roof  of 
the  mouth  close  to  the  alveolus.  This  is  carried  through  the  mucous 
membrane  and  periosteum.     A  muco-periosteal  flap  is  then  raised  by 


Fig.  69.  Fig.  70. 

Diagrams  of  Wyeth's  method  of  displacing  alveolar  fragment. 

blunt  dissection  from  the  bone,  to  be  subsequently  laid  over  the  cleft 
in  the  palate  with  its  raw  surface  toward  the  mouth.  No  incision  is 
made  along  the  margin  of  the  cleft,  because  the  flap  has  its  hinge 
there  and  obtains  its  blood  supply  from  that  source.     On  the  other 


Fig.  71. — Diagram  of 
Lane's  method.  Dotted  Unes 
show  incisions.  Shaded  por- 
tion shows  undermined  muco- 
periosteum;  F,  flap. 


Fig.  72. — Diagram  of  Lane's 
method.  .4,  alveolus;  R,  raw  surface 
left  after  flap  has  been  everted  and 
sutured  across  the  cleft. 


side  of  the  cleft  a  linear  antero-posterior  cut  is  made,  through  the 
mucous  membrane  and  periosteum,  along  the  edge  of  the  fissure,  and 
a  flap  is  raised  from  the  bone  by  undermining.  The  edge  of  the 
everted  flap  from  the  opposite  half  of  the  palate  is  tucked  under  this 


126 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


undermined  flap  and  secured  by  two  rows  of  sutures  introduced  by 
means  of  sickle-shaped  needles. 

The  flap,  which  is  to  cover  the  fissure  of  the  palate,  and  which  is 
everted,  is  cut  from  the  wider  portion  of  the  bony  palate.  If  there 
be  no  molar  teeth  present,  it  may  be  made  very  large,  when  necessary, 
by  including  in  its  area  the  fibro-mucous  membrane  covering  the 
alveolus  and  even  some  of  the  mucous  membrane  lining  the  cheek 


Fig.  73. — Diagram  of  Lane's  method.     Cross  section  showing  how  flap  F  has  had  its  edge  thrust 
and  sutured  under  the  undermined  muco-periosteum  on  opposite  side  of  cleft. 

beyond  the  alveolus.     The  soft  palate  tissues  are  treated  in  a  similar 
though  not  identical  manner. 

This  method  leaves  good  circulation  in  both  flaps  and  presents  the 
raw  surface  of  the  large  flap  toward  the  mouth.     The  tongue  is  there- 


FiG.  74. — Diagram  of 
Ijane's  method  showing  how 
the  flap  may  be  made  from 
surface  of  alveolus;  and  the 
opposite  part  of  soft  palate 
split. 


Fig.  75. — Diagram  of  Lane's 
method  showing  large  flap  cut  from 
palate,  alveolus  and  cheek  and 
everted.  R,  raw  surface  after  eversion. 


fore  able  to  keep  the  raw  surface  free  from  secretion  and  the  stitch- 
holes  are  therefore  less  likely  to  become  infected.  There  is  probably 
no  method  of  uranoplasty  which  gives  the  possibility  of  so  much 
tissue  to  be  utilized  without  injurious  tension  on  the  sutures. 

In  clefts,  which  have  the  two  sides  of  the  roof  of  the  mouth  in- 
clined toward  each  other  like  a  Gothic  arch,  this  method  has  perhaps 
not  the  same  advantages  as  in  the  cases  with  a  flattened  arch.     In 


CLEFT  PALATE 


127 


the  high  arched  cases  Brophy's  method  of  operating  on  palates  which 
are  too  sohd  for  the  "tie-beam"  method,  is  very  satisfactory. 

He  raises  two  muco-periosteal  flaps  by  undermining  the  tissues 


Fig.  76. — Diagram  of  Brophy's  method  of  detaching  the  two  muco-periosteal  flaps  by  undermin- 
ing from  the  cleft  toward  the  alveolus. 

on  the  inferior  surface  of  the  fissured  bony  palate.  Each  flap  is 
raised  by  an  incision  made  at  the  edge  of  the  cleft.  There  is  no  cut 
made  near  the  alveolus  as  in  the  Langenbeck  and  the  Fergusson 


Fig.  77. — Diagram  of  soft  palate  detached  from  posterior  edge  of  palate  bones  as  insisted 
upon  by  Brophy.  Dotted  lines  show  position  of  muco-periostum  and  velum  before  tissues  are 
detached. 


operations.  The  undermined  flaps  are  brought  together  edge  to  edge 
in  the  middle  line.  Wire  sutures  carried  through  the  flaps  near  their 
attachment  to  the  bone  are  passed  through  leaden  plates,  or  splints 


128  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

and  twisted.  These  tension  sutures  and  splints  steady  the  soft  flaps 
and  lessen  the  tendency  of  the  other,  or  coaptation  sutures,  which 
unite  the  raw  edges  of  the  flaps,  to  cut  out.  The  coaptation  sutures 
should  include  in  the  stitch  from  1/3  to  1/2  inch  of  tissue  on  each  side 
of  the  palatal  gap. 

The  soft  palate  should  be  freely  detached  from  the  posterior  edge 
of  the  hard  palate  before  the  sutures  are  inserted.  This  step  is  of 
the  utmost  importance.  It  permits  the  velum  and  uvula  to  drop 
toward  the  mouth  and  greatly  facilitates  the  repair  of  the  cleft  without 
tension  on  the  stitches.  It  lowers  the  roof  of  the  mouth,  which  is 
created  by  the  surgeon,  to  a  level  nearer  the  surface  of  the  tongue 


Fig.  78. — Curved  periosteal  separator  for  cleft-palate  operation. 

than  would  otherwise  be  the  case.  This  is  of  no  special  disadvantage, 
for  the  surgical  problem  is  to  close  the  communication  through  the 
partition  separating  the  nose  and  mouth.  This  object  can  be  ac- 
complished with  much  greater  probability  of  success,  if  the  detach- 
ment of  the  muscular  palate  from  the  posterior  edge  of  the  palatal 
bony  plates  is  assured.  The  detachment  is  made  by  a  transverse 
cut  through  the  mucous  membrane,  running  from  the  floor  of  the  nose 
over  the  upper  surface  of  the  soft  palate,  and  the  underlying  fibrous 
aponeurosis  fastening  the  soft  palate  to  the  sharp  bony  edge  of  the 


Fig.  79. — Angular  periosteal  separators  of  different  shapes  for  cleft-palate  operations. 

palate  process.  The  incision  may  easily  be  made  with  a  pair  of  small 
scissors  and  must  be  carried  to  the  outer  corner  of  the  palate  process 
on  each  side  of  the  cleft. 

The  more  vertical  the  sides  of  the  arch,  made  by  the  two  halves 
of  separated  palate,  are,  the  greater  width  will  the  two  muco-perios- 
teal  flaps  possess.  When  these  parallel  flaps  are  cut  loose  from  the 
back  edge  of  the  bone,  with  a  small  scissors  or  a  knife  making  a  trans- 
verse incision  on  the  nasal  side  of  the  soft  palate,  the  relaxation  of  the 
structures  to  be  sutured  in  the  middle  line  will  often  be  surprising. 
The  detachment  of  the  muco-periosteum  from  the  lower  or  oral 
surface  of  the  palate  processes  is  often  a  tedious  operation.  It  is 
accomphshed  with  small  angular  or  hoe-shaped  palate  knives  or  ele- 


CLEFT  PALATE  129 

vators.  These  are  of  varied  shapes  and  need  to  be  left  and  right 
handed  as  to  the  cutting  edge.  Care  should  be  taken  not  to  interfere 
too  much  with  the  blood  supply  of  the  flaps  near  the  anterior  end  of 
the  cleft  by  detaching  the  muco-periosteum  from  the  bone  immedi- 
ateh'  behind  the  incisors. 

Occasionall}^  it  may  be  necessar}^  to  raise  the  flap  on  one  side  in 
the  manner  preferred  by  Brophy,  on  the  other  in  the  way  used  by 
Langenbeck  and  Sir  William  Fergusson.  In  Brophy's  operation  the 
flap,  as  has  been  described,  is  raised  from  the  edge  of  the  fissure 
toward  the  teeth  on  both  sides.  The  other  method  is  to  make  an 
incision  down  to  the  bone  close  to  the  alveolar  process  and  lift  up  the 
flap  toward  the  median  line.  Sometimes  in  Brophy's  method  a  short 
incision  parallel  to  the  fissure  may  be  needed  to  relax  tension  on  the 
soft  palate,  and  should  be  made  through  the  mucous  membrane  and 
submucous  structures  near  the  molar  teeth  or  the  pillars  of  the  fauces. 
This  is  not  usually  required,  I  think,  and  is  very  different  in  its  effect 
on  the  blood  supply  of  the  flaps  from  the  long  cut  parallel  to  the  teeth 
made  in  the  Fergusson  operation.  The  latter  greatly  lessens  the 
circulation  in  the  flaps,  especially  if  it  is  carried  back  far  enough  to 
divide  the  descending  palatine  artery  just  after  it  comes  through  the 
posterior  palatine  canal. 

The  tensor  and  elevator  muscles  of  the  palate  should  not  be  divided 
with  the  tenotome,  nor  should  the  hamular  process  of  the  sphenoid  bone 
be  detached  by  a  chisel.  These  devices,  which  formerly  were  much 
used,  are  unnecessary  in  all  or  nearly  all  cases  and  add  to  the  com- 
plications of  the  operation.  As  a  result  of  their  use  there  may  occur 
great  bleeding  and  impaired  circulation  in  the  flaps.  Interference 
with  hearing  and  the  production  of  a  rigid  and  immovable  soft  palate 
may  perhaps  occur  as  a  late  effect.  The  sutures  which  may  be  in- 
serted first  at  the  posterior  or  anterior  end  of  the  cleft,  as  is  con- 
venient, should  not  be  taken  out  until  after  a  week  or  ten  davs, 
as  a  rule.  If  any  of  them  cut  the  tissues  or  become  markedh'  septic, 
those  may  be  removed  earlier. 

As  a  recapitulation,  then,  a  child  born  with  harelip  and  cleft 
palate  should  be  treated  by  what  might  be  called  the  composite 
method: 

1.  Immediately  after  birth  the  mother  should  press  the  two  halves 
of  the  upper  jaw  together  firmly  with  her  fingers  two  or  three  dozen 
times  a  day.  This  orthopedic  procedure  tends  to  lessen  the  width  of 
the  fissure. 

2.  As  soon  after  birth  as  possible,  the  soft  and  semi-cartilaginous 
bones  of  the  upper  jaw  should  be  forced  together  by  means  of  a  clamp 

9 


130  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

or  by  the  more  formal  operation  of  Brophy,  with  wire  tie  beams  and 
lead  plates. 

3.  About  the  same  time  that  this  replacement  of  the  bones  is 
attempted,  the  alveolus  should  be  reconstructed  in  front,  if  there 
be  any  great  deviation  in  the  alignment. 

4.  Any  protrusion  of  the  intermaxillary  bone  must  be  corrected 
by  a  plastic  or  osteoplastic  operation  at  the  front  part  of  the  septum 
of  the  nose. 

5.  A  gap  remaining  in  the  roof  of  the  mouth  must  next  be  closed 
by  a  flap  operation. 

6.  The  fissure  in  the  upper  lip  must  not  be  operated  upon  until 
then  and  should  be  closed  with  carefully  applied  sutures  and  the  de- 
formity of  the  nostril  corrected. 

7.  If  the  lower  lip  is  conspicuously  prominent,  a  V-shape  piece 
must  be  excised;  and  perhaps  the  upper  lip  widened  by  insertion  of 
this  tissue  or  a  flap  taken  from  cheek,  chin,  or  hand. 

These  various  operative  steps  will  occupy  probably  a  year  or  two, 
because  many  periods  of  inactivity  will  be  demanded,  in  order  to 
insure  safety  to  the  child  and  to  permit  the  surgeon  to  see  the  effect  of 
the  various  stages  of  the  operative  work. 

After  the  flap  operation  for  closing  the  palate  cleft,  great  care 
must  be  taken  to  keep  the  parts  clean  by  flushing  out  the  nose  and 
spraying  the  palate  with  a  weak  antiseptic  or  a  normal  saline  solution. 
The  patient  may  be  kept  quiet  by  small  doses  of  chloral  and  paregoric. 
Some  operators  feed  by  the  rectum,  others  put  food  in  the  stomach 
by  means  of  a  small  tube  introduced  through  the  nose.  I  feed  by  the 
mouth  with  liquid  food,  and  endeavor  to  keep  the  suture  wounds 
moderately  clean  with  spraying  and  swabbing. 

I  have  used  obturators  in  adult  cases  because,  at  one  time,  I  felt 
that  cleft  palate  operations  were  almost  uniformly  unsuccessful.  The 
modern  improvements  in  the  operation,  however,  have  convinced  me 
that  plastic  reconstruction  of  the  palate  is  better  than  the  use  of 
mechanical  obturators  with  a  movable  velum.  These  cannot  be 
worn  until  the  child  has  attained  nearly  the  age  of  adolescence.  Then 
the  secondary  atrophy  of  the  nasopharynx  and  facial  skeleton  have 
become  established  and  the  speech  defects  confirmed.  Mechanical 
appliances  are,  therefore,  to  be  usually  rejected  in  the  consideration 
of  the  treatment  of  congenital  clefts  of  the  palate.  They  may  at 
times  be  employed  when  the  patient  has  been  allowed  to  grow  up 
without  operative  treatment  in  infancy;  but  they  are  even  then  a  poor 
makeshift  for  reconstructive  treatment  by  operation. 

In  all  cases  of  this  congenital  anomaly  systematic  instruction  in 


CLEFT  PALATE 


131 


respiration  and  speech  should  be  begun  immediately  after  the  palate 
has  been  repaired  by  operation.  The  child  must  dilate,  as  it  were, 
the  nasopharynx  and  accessory  sinuses  of  the  nose,  and  train  the 
muscles  of  phonation,  as  well  as  the  corresponding  brain  centers, 
to  do  their  full  physiological  duty.  Children  should  be  subjected  to 
operation  early  enough  to  have  a  fair  reconstruction  of  the  parts 
before  they  begin  to  talk.  Careful  training  in  speech  will  greatly 
increase  the  mobility  of  the  palate  muscles  and  the  superior  con- 
strictor of  the  pharynx.     In  addition  to  the  benefit  to  speech,  the 

no 


Fig.   8o. 


Fig.   8i. 


Fig.  80. — Davies-Colley  operation.  Shows  flaps  EF  and  CD  to  be  cut  from  edges  of  cleft, 
are  then  to  be  everted  and  sutured  together  to  close  floor  of  nose  as  seen  in  figure  81.  GH,  out- 
line of  flap  to  cover  EF  and  CD  when  they  are  everted. 

Fig.  81. — Shows  flaps  EF  and  CD  stitched  together. 

early  closure  of  the  roof  of  the  mouth  may  save  the  child  from  infec- 
tions of  the  throat,  nose,  and  pharynx,  and  secondary  inflammation 
of  the  middle  ear. 

At  times  the  surgeon  may  find  it  necessary  to  deviate  from  these 
typical  methods  of  operating  because  of  some  peculiarity  in  the  case 
before  him.  Uranoplastic  operations  and  staphylorrhaphy  must  at 
times  be  atypical. 

The  methods  of  Davies-Colley  and  of  Lane  are  described  be- 
cause of  their  possible  availability  in  certain  instances.  Davies- 
Colley  dissects  a  wide  flap  of  oral  muco-periosteum  from  one  side 
of  the  cleft,  with  a  hinge  at  the  border  of  the  fissure,  and  a  similar 


132 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


though  narrower  flap  from  the  other  border  and  side  of  the  fissure. 
These  are  everted  across  the  gap  and  stitched  together  with  their 
mucous  surfaces  toward  the  nose.  Then  he  dissects  from  the  oral 
surface  of  the  hard  palate,  at  the  side  of  the  narrower  flap  just  de- 
scribed, a  long  tongue  of  muco-periosteum,  having  its  pedicle  near  the 
posterior  palatine  canal.  This  flap  is  swung  obliquely  across  the 
cleft,  now  closed  with  the  apposed  everted  flaps,  and  fastened  with 
sutures  in  its  new  position.  The  muco-periosteum  covering  the  oral 
aspect  of  the  hard  palate,  on  the  side  opposite  to  that  from  which  the 


/"D 


Fig.  82. — Davies-Colley  operation  shows  flaps  EF  and  CD  covered  with  flap  GH  outlined  in 
figure  80.  It  has  now  been  fastened  to  edge  of  muco-periosteal  on  opposite  side  of  cleft.  BA  is 
relaxation  incision. 


tongue  of  tissue  has  been  raised,  has  been  undermined  in  order  to  let 
it  slide  toward  the  median  line  to  meet  the  tongue  flap  swung  over  the 
fissure.  The  two  approximated  edges  are  united  with  sutures.  A 
relaxation  incision  has  previously  been  made  near  the  last  molar 
teeth  of  the  side  opposite  that  of  the  tongue  shaped  flap.  This  inci- 
sion also  gives  access  for  the  surgeon's  instrument  to  raise  the  flap 
from  the  bone  before  he  slides  it  toward  the  middle  line,  to  split  the 
soft  palate  in  its  horizontal  plane  when  necessary,  and  to  cut  the 
nasal  mucosa  and  the  aponeurosis  of  the  soft  palate  transversely  from 
the  back  edge  of  the  bony  palate. 

The   operations   used   by   Lane   to   meet   varying   conditions   are 
shown  in  the  illustrations.     They  are  modifications  of  his  method 


CLEFT  PALATE 


133 


described  above.  They  are  based  on  the  idea  that  large  flaps  may  be 
obtained  by  using  the  mucous  covering  of  the  gums,  when  operation 
is  done  before  the  eruption  of  the  teeth,  and  by  splitting  the  soft 


Fig.  83. — Flap  to  be  everted 
may  be  cut  from  tissues  on  gum, 
if  teeth  have  not  yet  appeared. 
{Lane.) 


Fig.  84. — Flap  everted  and 
sutured  after  being  dissected  up  as 
shown  in  figure  83.      {Lane.) 


palate  in  its  horizontal  plane.  Another  important  feature  of  his 
method  is  the  eversion  of  flaps  and  the  maintaining  of  them  in  that 
position  by  tucking  them  under  another  flap.     The  everted  flap  is 


Fig.  85. — Flap,  ABC  D, 
everted  may  be  irregular  in 
shape.  GFE  show  where  soft 
palate  is  split.      {Lane.) 


Fig.    86. — Flap    everted    and 
sutured.      {Lane.) 


maintained    comparatively    free    from    septic    inflammation    by    the 
ready  cleansing  it  may  receive  from  the  patient's  tongue. 

When  the  cleft  is  wide  in  well  grown  children,  division  of  the  hard 


134 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


palate  on  each  side  of  the  gap  and  displacement  of  the  resulting  bony- 
strips,  with  their  mucous  coverings  undisturbed,  toward  the  middle 
line  have  been  adopted.  The  sections  of  the  bone  should  be  made 
with  a  chisel  about  1/4  inch  from  the  fissure  and  the  fragments  should 


Fig.  87. — Alveolus  bared  and 
muco-periosteal  flap  divided  into 
three  portions.  The  anterior, 
ABFE,  is  everted  and  covered 
with  the  lateral  portions  which 
are  drawn  over  it.      {Lane.) 


Fig.  88. — The  position  of  the  su- 
perimposed flaps  in  figure  87  shown 
after  being  sutured.      {Lane.) 


be  held  together  with  wire  sutures.  This  type  of  operation  was 
formerly  adopted  not  infrequently.  It  is  seldom  used  now,  because 
less  severe  methods  have  been  found  satisfactory.  A  risk  of  necrosis 
of  the  osseous  flaps  is  inherent  in  this  procedure,  because  it  is  im- 


FiG.    89. — Splitting  velum  in 
clefts  of  soft  palate.     {Lane.) 


Fig.    90. — Flaps  from  soft  palate 
sutured  to  close  cleft.      {Lane.) 


possible  to  thoroughly  protect  the  operative  field  from  septic  con- 
tamination. 

Atypical  operations  for  fissured  palate  include  those  in  which  the 
bony  roof  of  the  mouth  is  patched,  as  it  were,  by  flaps  of  bone  and 
mucous  membrane  taken  from  the  septum  or  the  lower  turbinal,  and 


CLEFT  PALATE 


135 


those  in  which  flaps  from  the  cheek,  the  tongue  and  even  the  forehead 
and  nose  have  been  similarly  utilized  in  attempts  to  close  the  palatine 
gap. 

After  successful  closure  of  the  cleft  in  the  pendulous  palate  it  is 
frequently  found  that  the  velum  is  short  and  rigid,  making  it  unavail- 
ing as  a  curtain    to    close  completely  the  nasopharynx  against  the 


Fig.  91. — Wide  cleft  of  soft  palate 
closed  by  splitting  veium  and  everting 
flaps.      {Lane.) 


Fig.  92. — The  same  with  sutures 
applied.      {Lane.) 


current  of  air  coming  up  from  the  trachea  during  phonation.  To 
avert  this  insufficiency,  the  operator  may  use  during  the  staphylor-. 
rhaphy  strips  of  mucosa  and  muscle  from  the  adjoining  palatopharyn- 
geus  muscle  on  each  side  and  stitch  these  flaps  together  in  the  middle 
line  of  the  palate.  Such  a  step  might  be  employed  as  a  secondary 
operation  to  lessen  the  rigidity,  and  increase  the  length,  of  the  soft 


Fig.   93. — Obturator  for  cleft  palate. 

palate  after  an  otherwise  successful  closure  of  a  soft  palate.  The  new 
palate  may  perhaps  be  made  more  flexible  and  longer  by  stretching  it 
by  frequent  pressure  with  the  forefinger  in  the  mouth. 

The  peculiar  articulation  in  speech  characteristic  of  cleft  palate 
patients,  is  due  to  their  inability  to  control  the  direction  of  the  cur- 
rent of  air  entering  the  oral  and  nasal  cavities.  This  is  due  to  the  free 
communication  between  the  chambers  through  the  roof  of  the  mouth., 
which  is  also  the  floor  of  the  nose,  and  the  want  of  control  of  the 


136  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

muscular  apparatus  of  the  mouth  and  pharynx.  When  the  abnormal 
oro-nasal  orifice  is  small,  the  defect  may  be  minimized  by  an  unusual 
facility  of  nervous  and  muscular  control  attained  by  the  patient. 
As  a  result  speech  may  be  almost  perfect.  I  have  seen  this  unusual 
success  in  an  adult  without  operation,  though  there  existed  a  con- 
siderable congenital  cleft  in  the  soft  palate.  The  superior  constrictor 
of  the  pharynx  had  become  so  powerful  and  agile  that,  with  the  as- 
sistance of  the  palatal  muscles,  practically  perfect  occlusion  of  the 
nasopharynx  was  unconsciously  secured  during  speech.  It  is  known 
that  shortness  alone  of  a  reconstructed  soft  palate  is  not  the  whole 
reason  for  the  persistent  defective  articulation.     Patients  with  short, 


Fig.  94. — Obturator  with  flexible  velum  in  position  in  wide  cleft  of  palate.     {From  Bryant  and  Buck.) 

but  otherwise  normal  palates,  may  speak  well  and  some  patients 
without  clefts  have  utterance  similar  to  that  of  those  with  congenital 
fissured  palates. 

The  desirability  of  the  velum  reaching  the  posterior  wall  of  the 
pharynx  during  speech  has  made  it  doubtful  about  the  wisdom  of  the 
entire  removal  of  the  pharyngeal  tonsil  before  cleft  palate  operations. 
Certainly  such  radical  excision  as  may  convert  the  mucosa  of  the 
pharynx  into  cicatricial  tissue  is  unwise.  Inflamed  and  hypertrophied 
conditions  of  these  so-called  adenoids  sometimes  may  perhaps  need 
treatment  of  a  medical  rather  than  of  a  radical  surgical  kind  prior 
to  the  uranoplasty. 

Early  operation  before  the  child  learns  to  talk,  will  obviate  to  a 
great  extent  the  acquirement  of  improper  methods  of  speech,  due  to 


CLEFT  PALATE 


137 


the  imperfect  anatomical  formation  and  consequent  non-use  of  the 
parts,  as  well  as  permit  the  cultivation  of  the  linguistic  functions  of 
the  brain  and  hearing.  Uranoplastic  operations  performed  after  the 
child  has  begun  to  speak  miss  the  inestimable  advantage  of  the  de- 
velopmental years  of  childhood. 

After  the  sutures  of  flap  operations  have  been  removed,  there 
may  be  gaps  in  the  line  of  union  due  to  some  stitches  tearing  out 
because  of  tension  or  sepsis.     These  holes  will  open  close  by  granula- 


FiG.  95. 


-Sagittal  section   of  head  showing  artificial  palate  or  obturator  in   position. 
{From  Bryant  and  Buck,  American  Practice  of  Surgery.) 


tion  within  a  week  or  two.  The  two  situations  at  which  these  defects 
most  frequently  occur  are  at  the  junction  of  the  hard  and  soft  palate 
and  just  behind  the  incisor  teeth.  If  they  do  not  soon  close,  their 
cicatrization  may,  if  they  are  small,  be  hastened  by  stimulation  with 
fused  silver  nitrate  or  slight  cauterization  with  some  more  active 
agent.  The  hot  iron  may  be  used  with  a  light  touch.  If  they  are 
large,  a  secondary  plastic  operation  may  be  requisite  to  cause  their 
edges  to  unite. 

Sometimes  the  whole  line  of  approximation  of  the  lateral  halves  of 
the  palate  fails  to  unite.  This  is  usually  due  to  sepsis,  to  too  great 
tension  of  the  flaps,  or  to  insufficient  length  of  tissue  in  the  loops  of 


138  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

the  coaptation  sutures.  As  the  operative  field  and  subsequent 
wound  are  never  aseptic,  the  tissues  should  be  subjected  to  com- 
paratively little  tension.  This  is  best  insured,  as  has  been  insisted 
upon  above,  by  freely  cutting  the  upper  layers  of  the  soft  palate 
loose  from  the  posterior  border  of  the  palatine  processes.  In  addition 
the  frequent  occurrence  of  suppuration  at  the  suture  punctures  make 
it  necessary  for  the  stitches  to  be  retained  in  position  for  a  week  or 
more. 

Unsuccessful  operations  from  these  or  other  causes  should  not  be 
repeated  too  soon,  since  the  inflamed  tissues  must  be  permitted  to 
regain  their  normal  firmness.  While  the  flaps  are  still  softened  by 
inflammatory  exudate,  newly  applied  sutures  can  hardly  be  expected 
to  hold  them  together.  Some  operators  re-operate  after  the  lapse  of  a 
few  weeks.  I  prefer  to  wait  for  from  six  weeks  to  two  months  unless 
the  unclosed  portion  of  the  cleft  is  limited. 


Fig.  96. — Artificial  palate  attached  to  rubber  nipple  for  infant  with  cleft  palate.  A,  pro- 
jections to  fix  palate  against  alveolus;  B,  rubber  nipple;  C,  soft-rubber  end.  (Claude  and 
F.  Martin.) 

Sometimes  the  surgeon  utterly  fails  to  close  the  gap  by  the  methods 
described  even  if  they  are  repeated,  because  the  flaps  have  sloughed. 
At  other  times  the  width  of  the  fissure  seems  to  preclude  a  successful 
result  because  of  the  lack  of  sufficient  available  tissue.  An  obturator 
with  a  flexible  velum  may  be  employed  more  or  less  satisfactorily  in 
some  cases.  Such  appliances  can  be  constructed  by  dentists  familiar 
with  the  necessary  mechanical  manipulations. 

A  wide  cleft  may  be  narrowed  by  an  intraoral  orthodontic  appara- 
tus, which  will  gradually  draw  the  alveolar  processes  toward  the 
middle  line  by  the  use  of  collars  fixed  to  the  molar  teeth  and  controlled 
with  screws  and  nuts.  It  should  be  worn  some  weeks  or  months 
before  the  plastic  operation  is  done. 

V.  P.  Blair^  has  reported  success  in  fissures  of  unusual  width  by 
doing  the  uranoplasty  in  two  stages.  The  incisions  are  made  along 
the  inner  edges  of  the  alveolar  processes  as  in  the  Langenbeck  method. 

1  Surgery,  Gynecology  and  Obstetrics,  March,  1911,  p.  289. 


CLEFT  PALATE 


139 


The  muco-periosteum  is  then  raised  from  the  bony  palate  on  each  side 
of  the  cleft  and  pushed  toward  the  fissure,  but  there  is  no  incision 
made  along  the  edges  of  the  gap.  Next  the  velum  is  freely  detached 
from  the  posterior  edge  of  the  hard  palate.  The  space  between  each 
flap  and  the  subjacent  bone  is  then  packed  with  non-poisonous,  anti- 
septic gauze,  so  as  to  thrust  the  flaps  toward  the  middle  line.     These 


Fig.  97. — Double  harelip  and  cleft  palate,  showing  flattening  of  upper  lip  after  closure  of 
gap  and  improvement  after  V-shape  excision  of  lower  Up.  Upper  Hp  should  now  be  made  less  tense 
by  plastic  reconstruction  as  suggested  in  this  chapter.      (Author's  patient.) 


flaps  in  a  few  days  become  thickened,  very  vascular  and  perhaps 
stretched.  The  second  stage  of  the  operation  is  then  performed  by 
making  cuts  along  the  edges  of  the  cleft  and  suturing  the  Langenbeck 
flaps  in  the  usual  manner.  In  other  cases  the  flaps  may  be  more  ex- 
tensive, and  permit  of  suturing  with  little  tension,  by  including  the 
mucosa  on  the  nasal  side  of  the  |)alate  processes  or  by  encroaching  on 
the  buccal  mucosa. 


140  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

In  enormous  clefts  a  long  skin  and  platysmal  flap  cut  from  the 
side  of  the  neck  and  front  of  the  chest,  with  its  pedicle  at  the  mandib- 
ular border  of  the  cheek,  may  be  thrust  through  a  buttonhole  incision 
under  the  mandible.  This  opening  enters  the  mouth  between  the 
cheek  and  alveolus.  The  flap  is  drawn  into  the  mouth  and  sewed  into 
the  palatal  gap  after  the  borders  of  the  latter  have  been  pared.  The 
skin  surface  should  present  toward  the  mouth  and  should  be  free  from 
hair  bulbs.  The  cervical  wound  is  to  be  sutured  at  once,  and  the 
pedicle  of  the  flap  divided  at  the  end  of  ten  days  or  two  weeks.  The 
teeth  must  be  kept  apart  by  an  intraoral  gag  during  the  time  the 
pedicle  is  uncut.  These  various  methods  are  probably  more  available 
in  patients  who  have  grown  to  adult  life  with  the  palatal  cleft  unclosed, 
than  in  infants. 

Pathological  perforations  of  the  roof  of  the  mouth  in  the  hard  or 
soft  portion  occur  principally  from  late  syphilitic  inflammation, 
though  they  may  arise  as  a  result  of  gangrene,  injury  or  malignant 
disease.  In  the  last  case  repair  by  operation  is  not  feasible.  In 
other  instances  plastic  operations  varying  with  the  character  and 
situation  of  the  opening  should  be  employed.  Abnormal  adhesions 
may  require  preliminary  surgical  action.  Obturators  fastened  to  the 
teeth,  similar  to  the  plates  with  which  artificial  teeth  are  retained 
in  position,  will  satisfactorily  prevent  food  and  air  from  passing 
through  small  openings  in  the  hard  palate.  Gaps  in  the  pendulous 
velum  can  usually  be  closed.  If  this  is  practically  impossible  or  if 
the  patient  refuses  consent  to  operation,  an  artificial  velum,  similar 
to  those  formerly  used  at  times  for  congenital  cleft  palate,  may  be 
adjusted  by  a  competent  dental  surgeon. 


CHAPTER  XI. 

CHEILOPLASTIC  OPERATIONS  NOT  CONNECTED  WITH  HARELIP 
AND  CLEFT  PALATE. 

Cheiloplastic  operations  may  be  required  to  correct  cicatricial 
eversion  or  other  distortions  of  the  lips  and  to  replace,  or  restore 
mobility  to,  lips  adherent  to  the  gums.  They  are  also  needed  to 
build  up  a  portion  of  a  lip  or  an  entire  lip,  lost  by  removal  of  tumors, 
some  destructive  injury,  or  gangrene.  Burns  of  a  necrotic  degree 
cause  various  grave  distortions  of  these  organs  from  scar  contraction, 
which  need  operative  reparation. 


Fig    98.  Fig.  99. 

Operation  for  fissure  of  upper  lip.      {After  Szymanowski.) 

Skin  and  superficial  fascia  for  making  pedunculated  flaps  are  cjuite 
readily  obtained  from  the  cheeks,  neck  and  shoulders.  Hence  lips 
may  be  constructed  with  comparative  ease,  unless  the  structures 
surrounding  the  mouth  have  been  destroyed  extensively  by  gangrene 
or  converted  into  fibrous  cicatrix  containing  a  limited  blood  supply. 

A  not  infrequent  disfigurement  here  is  eversion  of  the  lower  lip 
from  burning  of  the  face  and  neck  by  fire  or  caustic  chemical  sub- 
stances. These  necrotic  burns  destroy  such  deep  masses  of  skin  and 
fascia  that  the  chin  is  tied  down  by  the  scar  to  the  chest  and  the  lower 
lip  is  everted  until  the  saliva  may  drip  over  its  exposed  and  thickened 
mucous  surface. 

141 


142 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Removal  of  epithelioma  of  the  lip,  gunshot  wounds  of  the  lower 
part  of  the  face  and  other  traumatisms  are  causes  for  reconstructive 
operations  in  this  region.  Phosphorus  necrosis  of  the  mandible, 
abscesses,  tumors  of  dental  origin,  and  undershot  mandible  may 
supply  the  surgeon  with  operative  opportunity. 

New  lips,  made  from  the  integument  of  the  chin  or  neck  or  from 


Fig.  100. 
Restoration  of  upper  lip. 


Fig.   101. 

{Modified  from  Szymanowski.) 


brachial  or  palmar  flaps,  when  necessary  may  be  lined  with  mucous 
membrane  taken  from  the  inner  surface  of  the  cheeks  or  upper  lip. 
Usually  this  is  not  demanded,  because  the  skin,  when  turned  in  so  as 
to  be  continuously  exposed  to  the  secretions  of  the  mouth,  is  con- 


_,i*;^s«Sj%,^,^  ,,#'^*^'' 


Fig.  102. 

Restoration  of  both  lips. 


Fig.  103. 

(After  Szymanowski.) 


verted  into  a  pseudo-mucous  membrane.     Raw  surfaces  of  fascia  and 
muscle  undergo  a  similar  transformation  under  the  same  influences. 

The  three  following  diagrams  show  how  an  upper  lip  may  be  con- 
structed by  sliding  and  rotating  flaps  of  the  integument  of  the  cheek 
into  the  upper  labial  region. 


CHEILOPLASTIC  OPERATIONS 


143 


They  are  taken  from  Szymanowsky's  Handbook  of  Operative 
Surgery.  Many  operations  in  plastic  surgery  described  by  later 
writers  are  practically  identical  with  the  suggestive  methods  long  ago 
planned  bj^  this  ingenious  surgeon. 

Deficiencies  of  the  lower  lip  may  be  repaired  by  inserting  flaps 
from  the  upper  lip  and  cheek  or  from  the  neck. 


Fig.  104.  Fig  105. 

Diagram,  of  method  of  making  lower  lip  from  tissue  over  mandible. 

These  illustrations  will  give  an  idea  of  the  various  forms  of  pedun- 
culated flaps  that  may  be  employed  when  the  new  tissues  are  obtained 
frohi  the  vicinity  of  the  mouth.  Often  it  may  be  found,  especially 
in  deformity  after  the  sloughing  of  burns,  that  no  sufficiently  vascular 


Fig.   106. 
Diagrams  of  methods  of  making  lower  lip  from  cheeks. 


and  elastic  tissue  can  be  secured  for  this  purpose  from  this  region. 
Then  free  flaps  of  skin  cut  from  the  thigh  or  abdomen  may  be  tried, 
as  suggested  by  Wolfe  and  Krause  for  grafting.  Sometimes  brachial 
flaps  with  pedicles  employed  after  the  Tagliacozzi  method  of  rhino- 


144 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Fig.  107.  Fig.  108. 

Restoration  of  whole  lower  lip.     (.After  Szymanowski.) 


Fig.  109.  Fig.  110. 

Buchanan's  operation  for  restoration  of  lower  lip. 


Fig.  111.  Fig.  112. 

Restoration  of  lower  lip.     {After  Serre.) 


CHEILOPLASTIC  OPERATIONS 


145 


plasty  or  flaps  from  thigh  or  alDclomen  transported  to  the  face  by 
first  phinting  them  in  the  tissues  of  the  hand  may  he  preferred. 

Cicatricial  deformities  of  the  face  from  Ijurns  often  demand  manv 


Fig.   113. — Reconstruction  of  lips  and  part  of  cheek.      (From  Szymanowski.) 

operations  on  chin,  lips,  nose,  eyes  and  ears  and  all  varieties  of  flaps 
are  used.  Long  flaps  from  the  back  or  chest  or  both  may  be  carried 
around  the  neck  to  allow  the  head  to  resunle  its  natural  attitude  on 
the  neck  and  shoulders. 


Fig.   114. — Reconstruction  of  lower  lip  and  chin  by  flaps  from  cheeks.      (From  Ssymanowski.) 

Construction  of  the  cheek,  or  meloplasty,  may  be  recjuired  after 
excision  of  tumors  or  sloughing;  or  gunshot  wounds  or  other  trauma- 
tisms carr^'ing  away  the  wall  of  the  buccal  cavity.  In  these  cases  it 
may  be  necessary,  if  the  mandible  be  partly  lost  to  have  an  appliance 


Fig.  115. — Reconstruction  of  lower  Hp  from  tissues  of  chin  and  neck.      (From  Szymanowski.) 

adjusted  to  the  teeth  to  hold  the  remnant  of  the  mandible  in  place 
during  cicatrization. 

This  may  consist  of  caps  cemented  to  the  upper  and  lower  teeth 
of  the  side  opposite  to  that  lost,  having  hooks  upon  them.  To  these 
hooks  rubber  bands  may  be  adjusted  so  as  to  hold  the  fragment  of  the 
mandible  in  proper  position  in  relation  to  the  middle  line  of  the  face. 

10 


146 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


An  artificial  j  aw  may,  if  needed,  be  made  of  vulcanized  rubber  and  even 
a  cheek  plumper  may  be  constructed  and  worn  to  fill  out  the  collapsed 

cheek. 

Hemiatrophy  of  the  face  gives  rise  to  an  unseemly  distortion  of 


Fig.  116. — Incisions  for  making  lower  lip  after  excision  of  tumor.     (Doivd.) 


Figs.  117  and  118. — Method  of  applying  splint  of  gypsum  when  making  lip  from 
abdominal  flap  transported  to  face  by  hand. 

the  features,  due  to  the  undeveloped  condition  of  the  facial  bones  on 
one  side.  For  an  instance,  recently  under  my  care  in  a  nursing  baby, 
I  am  considering  ligation  of  the  external  carotid  on  the  well  developed 
side.     This  will  throw  more  blood  into  the  smaller  side  of  the  face  and 


CHEILOPLASTIC  OPERATIONS 


147 


lessen  the  flow  for  a  time  at  least  to  the  larger  side.  For  the  present 
I  am  trying  the  effect  of  massage  of  the  soft  parts  on  the  atrophic  side. 

The  obliquity  of  the  mouth  due  to  palsy  of  the  facial  nerve  may  be 
improved  somewhat  by  excising  an  elliptical  portion  of  the  tissues  of 
the  skin  and  careful  suturing  of  the  skin  edges. 

Anastomosis  of  the  spinal  accessory  nerve  to  the  distal  portion  of 


Fig  119. 


Fig.  120. 


Fig.   121.  Fig.   122. 

(junshot  wound  of  face,  carrying  away  a  large  portion  of  the  ramus  and  body  of  mandible. 

Reconstruction  of  cheek  from  dorsal  and  pectoral  flaps.      (Author's  patient.) 

the  paralyzed  facial  nerve  has  given  power  to  the  muscles  of  the  face 
supplied  by  the  inactive  nerve  trunk. 

Errors  in  the  ''bite"  or  articulation  of  the  teeth,  prominence  of  the 
mandible,  contracted  upper  jaw  and  other  deformities  are  quite  readily 
lessened  or  entirely  removed,  if  attacked  in  the  adolescent  period,  say 
between  twelve  and  twenty  years  of  age.  Those  familiar  with  the 
physiology  of  dentition  and  accustomed  to  mechanical  dental  opera- 
tions are  the  proper  guides  of  the  surgeon  in  these  cases.  Orthodontic 
operations  need  many  months  to  obtain  good  results,  because  physiologic 
methods,  which  are  requisite,  never  act  hastily.  The  surgeon  should 
refrain  from  extracting  teeth,  which  seem  to  be  misplaced,   unless 


148 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


sure  of  the  necessity  therefor.  Much  harm  may  be  done  by  remov- 
ing the  canine  teeth,  especially,  for  they  have  a  great  influence  on 
the  shape  of  the  growing  face. 

Mr.  W.  Arbuthnot  Lane  has  been  foremost  among  English  speak- 
ing surgeons  in  calling  attention  in  facial  surgery  to  the  necessity  of 
considering  the  physiology  of  dentition  and  the  factors  that  affect 
the  development  of  the  mouth,  the  nasopharynx  and  the  adjacent 
bones.  The  flat  temporSTmaxillary  joint  and  the  nut-cracker  face 
due  to  the  edentulous  mandible  of  the  a,ged,  the  synostosis  of  that 
joint  from  ankylosis  in  early  age,  the  atrophy  of  the  orbit,  when  an 
eye  becomes  blind  and  disorganized  in  childhood,  the  change  in  the 


Fig.  123. — Gunshot  wound  of  face,   carrying  away  a  large  portion  of  the  ramus  and  body  of 
mandible.      Reconstruction  of  cheek  from  dorsal  and  pectoral  flaps.      (Author's  patient.) 

maxillae  from  obstruction  of  the  nasal  chambers  and  nasopharynx, 
and  the  distortion  of  the  lower  part  of  the  face,  when  the  tongue  is 
hypertrophic,  are  all  instances  of  surgical  deformities  arising  secondary 
to  impairment  of  function.  Insertion  of  artificial  dentures,  excision 
of  ankylosis  joints,  the  wearing  of  artificial  eyes  and  the  removal  of 
nasal  and  post-nasal  obstructions  will  bring  the  desired  cosmetic 
result,  if  the  surgeon  acts  promptly.  If  he  delays,  growth  and  habit- 
ual use  may  be  unable  to  serve  him,  because  nature  has  already 
established  a  new  and  abnormal  relation  of  the  structures. 

In  open  bite  and  underhung  bite  the  teeth  articulate  improperly 
and  may  require  mechanical  treatment  by  a  dentist  to  obtain  proper 
dental  relation.     The  open  bite  due  to  improper  contact  of  the  molar 


CHEILOPLASTIC  OPERATIONS 


149 


teeth  may  be  removed  at  times  by  simply  shortening  the  molar  teeth. 
At  other  times  the  open  jaws  may  reciuire  the  excision  of  a  V-shaped 
piece  of  the  body  of  the  jaw  on  each  side  with  subseciuent  wiring  of 
the  fragments.     Lane  reports^  a  very  instructive  case  of  the  kind. 

The  great  error  of  allowing  this  and  similar  malformations  to  per- 
sist is  manifest.  No  more  significant  illustration  can  be  given  than 
that  of  congenital  harelip  and  cleft  palate.     In  infants  a  few  days 


Fig.  124. — Lane's  case  of  open  bite,  treated  by  a  V-shapc  ust 

Tongue  was  hypertrophied. 


■tomy  of  the  body  on  each  side. 


old  the  separated  maxillae  and  palate  bones  can  be  pressed  together 
with  the  thumb  and  forefinger  of  the  observer.  The  edges  of  the 
fissure  in  the  lip  then  nearly  or  quite  touch  each  other.  After  a  few 
months,  however,  the  deformity  has  become  established  by  ossification 
of  the  previously  cartilaginous  bones,  and  the  gap  perhaps  widened  by 
the  action  of  the  mandible  and  tongue  against  the  separated  halves  of 
1  "Cleft  Palate  and  Harelip,"  London,  1905,  p.  13. 


150 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


the  roof  of  the  mouth.     Early  operation  is  demanded  before  these  un- 
desirable consequences  of  delay  have  occurred. 


Fig.   125. — Skiagraph  of  Lane's  case  of  open  bite  before  operation. 


Fig.   126. — Cast  of  Lane's  case  of  open  bite  Isefore  operation. 


Superior  protrusion  of  the  teeth,  crowding  of  the  teeth  and  other 
irregularities  are  associated  with  deficiencies  in  the  development  of 


CHEILOPLASTIC  OPERATIONS 


151 


the  palate  bones,  the  maxillae,  the  alveolar  arches,  the  accessory  sinuses 
of  the  nose,  the  nasopharyngeal  chaml^ers,  and  the  mandible.     The 


Fig.   127. — Cast  of  Lane's  case  of  open  bite  after  operation. 


Fig.  128. — Depressed  fracture  of  right  upper  maxilla.     Deformity  was  relieved  by  incision  and 
elevation  of  the  fragment.     {Author's  patient.) 


integrity  and  growth  of  these  structures  are  dependent  to  a  certain 
extent  upon  the  activities  and  general  health  of  the  individual  ado- 
lescent.    Conversely,  the  health  and  possibilities  of  activity  of  the 


152  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

patient  are  related  to  the  integrity  of  his  dental,  respiratory  and 
digestive  organs.  It  will  therefore  be  seen  that  no  mere  operation  can 
be  a  satisfactory  solution  of  these  facial  disturbances.  Hygienic  and 
medicinal  aids  must  also  be  part  of  the  surgeon's  equipment. 

A  very  valuable  contribution  to  this  subject  has  been  made  by 
W.  Wayne  Babcock,  who  has  reported  cases  of  satisfactory  operation 
for  malocclusion  of  the  teeth. ^ 

Deformities  of  the  contour  of  the  cheeks  and  surrounding  structures 
may  occur  fro.m  depressed  fractures  of  the  zygoma,  the  malar  bone, 
and  the  upper  jaw.  Enophthalmos  from  fracture  of  the  orbital  walls 
may  not  be  very  susceptible  of  operative  treatment.  Hollows  in  the 
zygomatic  or  malar  region  are  often  easily  obliterated  by  elevating 
the  driven  down  bone  with  a  steel  elevator,  introduced  through  an 
appropriate  incision.  I  have  relieved  restricted  motion  of  the  man- 
dible by  thus  restoring  the  space  under  the  zygomatic  arch,  in  which 
the  coronoid  process  slides  during  the  action  of  the  temporal  muscle. 
Hollows  may  also  be  filled  by  injecting  melted  paraffin,  which  becomes 
solid  on  cooling. 

^Journal  of  American  Medical  Association,  September  11,  1909,  p.  833. 


CHAPTER  XII. 

DEFORMITIES  OF  THE  EXTERNAL  EAR. 

Congenital  Anomalies  of  the  Auricle. 

The  external  ear  may  be  congenitally  absent,  its  position  occu- 
pied by  irregular  masses  of  cartilages  and  integument,  or,  in  addition 
to  a  normal  or  nearly  normal  auricle,  there  may  be  supernumerary 
auricles.  Sometimes  the  auricle  is  represented  by  only  a  tag  of  in- 
tegument or  by  nodules  of  cartilage  under  the  skin  of  the  cheek. 
Interspersed  among  these  are  seen  perhaps  one  or  two  sinuses  running 
inward  from  the  surface.     There  is  occasionally  no  evidence  of  an  ex- 


FiG.  129. — Congenital  deficiency  of  ear.      {Author's  patient.) 

ternal  auditory  meatus  in  the  soft  or  bony  structures,  although  there 
may  be  a  considerable  though  irregularly  formed,  external  ear.  At 
times  a  fistulous  track  or  sinus  may  lead  through  the  soft  tissues 
to  an  imperfect  meatus  in  the  temporal  bone.  These  deviations 
from  the  normal  are  the  result  of  disturbances  in  the  closure  of  the 
first  two  branchial  clefts. 

In  incomplete  absence  of  the  auricle  it  may  be  the  lobule  that  is 
not  developed,  or  the  helix  and  the  associated  parts  only  may  show 

153 


154  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

arrested  or  imperfect  embryological  formation.  The  lobule  may  have 
a  more  or  less  vertical  fissure  dividing  it  into  two  segments.  Occa- 
sionally one  ear  is  very  small;  at  other  times  the  organ  on  one  side 
may  be  unnaturally  large.  Either  of  these  abnormalities  may  be  pres- 
ent in  both  ears.  Supernumerary  ears  of  perfect  or  imperfect  form 
are  occasionally,  though  rarely,  seen.  They  may  be  situated  on  the 
cheek,  neck,  shoulder  or  back. 

The  congenital  sinuses  frequently  seen  in  connection  with  irreg- 
ularities in  the  development  of  the  auricle  are  lined  with  epithelium. 
They  are  due  to  defective  coalescence  of  the  various  segments  which 
are  concerned  in  the  embryonic  formation  of  the  external  ear.  They 
may  become,  from  retained  secretion,  the  seat  of  inflammation  and 
abscess,  or  of  retention  cysts.  The  whole  sinus  should  be  dissected 
out,  if  it  causes  trouble  or  is  unsightly. 


Fig.     130. — Normal    ear    of       Fig.  131. — Partially  constructed 
patient  shown  in  Fig.  129.  new  ear  of  same  patient 

Abnormalities  in  the  development  of  the  external  ear  are  believed 
by  some  to  be  suggestive  of  membership  in  the  defective  and  criminal 
classes.  The  occasional  absence  of  the  usual  fissure  between  the 
lobule  and  the  neck  similarly  is  considered  to  be  indicative  of  the 
lower  classes  of  humanity.  A  great  development  of  the  lobule  is  seen 
in  some  of  the  lower  types  of  mankind.  A  cartilaginous  elevation  on 
the  edge  of  the  helix,  which  gives  the  ear  a  pointed  appearance,  has 
been  called  the  Darwinian  tubercle,  because  it  is  suggestive  of  the 
ears  of  the  apes.  It  is  apt  to  be  situated  at  the  junction  of  the  upper 
and  middle  part  of  the  border  of  the  auricle.  Cartilaginous  excres- 
cences may  be  attached  to  the  tragus  also. 

Absence  of  the  external  auditory  meatus  is  not  uncommon  in 
cases  of  congenital  malformation  of  the  ear.  Sometimes  there  is 
a  mere  atresia  with  a  well  developed  bony  orifice  in  the  petrous  portion 
of  the  temporal  bone.     At  other  times  the  bone  is  abnormal  and  no 


DEFORMITIES  OF   THE  EXTERNAL  EAR  155 

canal  into  the  bone  is  to  be  found  even  when  the  soft  tissues  are  dis- 
sected up.  In  searching  for  the  bony  orifice  during  plastic  operations 
for  restoration  of  the  shape  of  the  auricle,  the  surgeon  should  remem- 
ber that  the  defective  auricle  may  not  be  situated  in  its  normal 
relation  to  the  bony  canal.  His  incisions  may  thus  fail  to  disclose  a 
bony  meatus  which  may  be  present  at  an  unexpected  point.  The 
doubt  as  to  the  existence  of  a  meatus  in  the  bone  may  possibly  be 
cleared  up  by  the  use  of  X-rays.  Such  a  method  is  not  very  satisfac- 
tory in  investigating  these  conditions  in  the  incompletely  ossified 
bones  of  infants. 

There  is  very  great  variety  in  the  convolutions  and  shape  of  normal 
ears;  but  so  long  as  the  two  are  symmetrical  and  not  unusually  large 
or  flaring,  little  complaint  is  made  by  their  owners.  The  most  deli- 
cately formed  and  graceful  auricles  may  be  found  in  unexpected 
individuals.  I  have  seen  very  beautiful  ears  in  the  negro  race;  and 
very  homely  and  coarse  ones  in  white  patients. 

A  large  auricle,  without  much  cartilaginous  support  and  with  the 
helix  imperfectly  curved,  may  look,  if  pointed  at  the  top,  very  much 
like  the  ear  of  an  animal.  It  has  been  called  the  satyr  ear.  A  thick- 
ened helix  bent  forward  and  downward  gives  the  lop  ear  or  scroll  ear, 
which  somewhat  resembles  the  ear  of  a  dog  or  cat.  Sometimes  this 
helix  is  attached  to  the  surface  of  the  apposed  portion  of  the  rest  of 
the  auricle. 

Supernumerary  ears  and  aberrant  nodules  should  be  excised  and 
the  scar  made  as  inconspicuous  as  possible.  Sufficient  skin  can 
usually  be  obtained  from  the  surface  of  the  prominent  portion  to 
close  the  wound  without  tension.  Therefore  a  depressed  or  con- 
torted cicatrix  may  readily  be  avoided.  Nodules  of  cartilage  should 
be  dissected  out  and  removed  radically,  lest  they  grow  and  cause 
tumor-like  masses.  If  a  series  of  plastic  operations  are  to  be  made  to 
reconstruct  a  deficient  auricle,  any  cartilaginous  nodules  in  the  vicinity 
should  be  retained  until  it  is  found  that  they  are  not  likely  to  be 
useful  in  flaps  or  grafts  to  give  rigidity  to  the  reconstructed  organ. 

It  would  be  possible  to  transfer,  or  even  perhaps  to  transplant,  a 
supernumerary  auricle  to  the  head  of  a  patient  born  without  an  ex- 
ternal ear.  Unfortunately,  no  surgeon  is  likely  to  have  a  patient 
with  congenital  absence  of  an  ear  under  his  care  at  a  time  wdien  the 
even  rarer  condition  of  supernumerary  ear  is  available  for  plastic 
purposes.  It  would  be  necessary  that  the  supernumerary  organ  be 
perfect  in  shape  or  nearly  so.  Otherwise  it  would  be  likely  to  prove 
more  satisfactory  to  pay  a  person  to  sacrifice  a  normal  auricle. 

The  transfer  could  be  made  directly  from  head  to  head  by  keeping 


156  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

donor  and  recipient  close  together  in  bed  for  two  or  three  weeks.  The 
ear  to  be  moved  would  be  allowed  during  this  time  to  receive  its  circula- 
tion through  a  broad  pedicle  connecting  it  with  its  original  owner. 
The  method  should  be  to  detach  the  donated  ear  from  above  downward 
and  have  the  pedicle  below  where  the  temporal  and  posterior  auricular 
arteries  would  remain  unsevered.  It  would  be  wise,  I  think,  to  include 
in  the  tissues  separated  from  the  donor's  skull  a  quite  large  extent 
of  skin  and  fascia  around  the  attachment  of  the  auricle,  in  order  to 
give  a  large  base  to  form  vascular  adhesions  to  the  tissues  of  the  recip- 
ient. I  should  be  inclined  to  insert  the  edges  of  this  base  under 
the  integument  of  the  recipient  after  freshening  the  upper  surface 
for  about  a  third  of  an  inch  from  the  margins.  After  two  to  three 
weeks  union  would  probably  be  sufficient  to  allow  division  of  the 
pedicle. 

The  other  method  would  be  to  first  attach  the  ear  to  the  hand  of 
the  donor  or  recipient  and  after  two  or  three  weeks  divide  the  pedicle 
connecting  it  with  its  original  site.  The  hand,  to  which  it  had  grown 
fast,  could  then  be  fixed  to  the  side  of  the  head  of  the  would-be  recipient 
and  suitable  sutures  inserted  to  secure  union  of  the  ear  in  the  proper 
situation.  Two  or  three  weeks  later  the  attachment  of  the  trans- 
ported ear  to  the  hand  should  be  cut. 

An  artificial  ear,  modelled  after  the  normal  ear  of  the  patient,  may 
be  made  of  vulcanite,  of  aluminum  coated  with  vulcanite,  or  of  cel- 
luloid, and  fastened  to  the  side  of  the  head  with  a  spring  bearing  upon 
the  internal  wall  of  the  external  auditory  meatus.  If  the  entire 
auricle  is  not  absent,  the  parts  remaining  may  be  used  for  the  attach- 
ment of  the  mechanical  representative  of  the  missing  portion.  Small 
cicatrized  orifices  may  be  made  in  the  remnants  of  the  ear,  as  is  doen 
for  the  wearing  of  earrings.  Through  these  openings,  delicate  wires 
and  bolts  with  nuts  may  be  carried  to  support  the  light  artificial  ear. 
When  the  surface  of  the  auricular  region  contains  no  hollows  or 
elevations  suitable  for  such  connections,  a  thin  aseptic  plate  or  band, 
of  silver  or  other  material,  might  be  inserted  under  the  skin  of  the  cheek 
or  scalp  and  allowed  to  become  encysted  there.  This  might  have  a 
screw  or  socket  projecting  through  a  cicatrized  opening  in  the  integu- 
ment, to  which  the  artificial  ear  may  be  attached.  Prosthetic  appli- 
ances of  this  character  are  troublesome  and  not  very  satisfactory 
in  the  long  run.  As  a  rule  it  is  better,  if  possible,  to  reconstruct  an 
ear  by  a  series  of  plastic  operations. 

Organs  repaired  by  permanent  displacement  of  human  tissues  are 
after  all  the  most  satisfactory.  It  requires,  however,  operative  skill 
on  the  part  of  the  surgeon  and  patience  and  confidence  on  the  part 


DEFORMITIES  OF  THE  EXTERNAL  EAR 


157 


of  the  subject  to  insure  even  a  moderately  successful  construction 
of  a  whole  ear  or  nose,  or  of  a  large  portion  of  the  face.  If  two  or 
three  years  be  allowed  for  successive  plastic  operations  and  these  are 
thoughtfully  devised  as  well  as  carefully  performed,  the  final  results 
may  readily  be  surprisingly  good.  Nature  cannot  be  excelled  in 
facial  development,  but  an  astute  surgeon  with  Nature's  assistance 
can  obtain  unexpectedly  good  results. 

In  congenital  absence  of  the  entire  external  ear  or  of  the  greater 
part  of  it  a  fair  substitute  may  be  constructed,  I  believe,  by  utilizing 
the  skin  and  subcutaneous  fascia,  and  stiffening  the  auricular  append- 


FiG.   132. — Szymanowski's  incisions  for  making 
an  auricle. 


Fig.    133. — Szymanowski's   method  of    m.odel- 
ing  the  auricle  made  from  cutaneous  flaps. 


age  SO  made  with  grafts  taken  from  the  costal  cartilages  of  the  patient 
or  some  other  person.  It  is  easy  to  cut  pieces  of  cartilage  of  various 
sizes  and  shapes  from  the  chest,  where  the  ribs  are  attached  to  the 
lower  part  of  the  sternum.  This  may  be  done  under  local  anesthesia. 
These  shavings  or  chips  may  be  introduced  into  the  flaps  used  for 
constructing  the  auricle  at  the  primary  operation  or  later.  It  is 
probably  best  to  make  a  rather  large  integumentary  ear  first  and 
stiffen  it  with  cartilaginous  grafts  afterward. 

Many  years  ago  Szymanowski  suggested  flaps  made  after  the 
method  shown  in  the  figures  here  copied.  I  have  employed  these 
incisions  and  believe  them  of  value. 

A  better  plan  of  operation  is  probably  that  which  I  have  used  with 
greater  satisfaction  and  which  is  shown  in  this  diagram.     Two  flaps 


158 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


with  tlieir  pedicles  downward  are  cut  from  the  skin  and  underlying 
fascia  of  the  side  of  the  head,  avoiding  the  hairy  parts  so  far  as  possible. 
They  get  a  good  blood  supply  from  the  temporal  and  posterior  auricular 
arteries.  Each  of  the  flaps  is  the  shape  of  a  boy's  shinny  stick. 
They  have  their  convex  borders  toward  each  other.  The  lower  part 
of  these  edges  should  be  in  contact  for  about  one-fourth  of  their 
length,  and  the  line  of  contact  should  run  a  little  obliquely  backward 
as  it  extends  upward.  The  incisions  outlining  the  flaps  diverge  as 
they  ascend.  The  two  flaps  in  the  upper  portion  of  their  extent  are 
separated  by  a  half  or  three-quarters  of  an  inch.  They  are  raised  and 
placed  together,  raw  surface  to  raw  surface.  Through  and  through  su- 
tures placed  at  needed  intervals  hold  the  raw  surfaces  smoothly  in  con- 


FlG.   134. — The  author's  incisions  for  making 
an  auricle. 


Fig.  135. — Patient  showing  promi- 
nence of  upper  portion  of  auricle  obtained 
by  author's  method. 


tact,  so  as  to  avoid  pockets  for  retention  of  blood  between  the  flaps. 
The  through  and  through  sutures  may  be  threads  of  pure  rubber 
with  shot  clamped  on  the  ends.  These  prevent  injurious  pressure 
by  stretching  during  inflammatory  swelling  and  contracting  when  it 
disappears.  The  two  flaps  have  their  edges  also  united  by  sutures. 
This  duplex  flap,  when  turned  on  its  concave  edge,  will  resemble  a 
crudely  shaped  ear.  It  should  have  its  concave  margin  beveled  and 
mortised  into  a  crescentic  incision  in  the  skin  at  the  position  which 
a  normal  ear  would  occupy.  Careful  suturing  with  silkworm  gut 
and  silk  will  accompHsh  this  without  much  difficulty.  The  wide  upper 
part  of  the  flap  should  be  curved  well  forward  so  as  to  represent  the 
broad  upper  part  of  the  external  ear.  Silver  wire  filigree  or  shavings 
of  costal  cartilage  may  be  subsequently  introduced  to  give  a  certain 
degree  of  rigidity  to  the  aural  substitute.     Modifications  in  shape  may 


DEFORMITIES  OF  THE  EXTERNAL  EAR  159 

be  made  by  repeated  small  operations.  The  essential  is  to  obtain  at 
first  a  bulky  mass  resembling  in  general  outline  the  other  ear.  Sub- 
sequent shrinkage  will  be  great  and  growth  may  not  keep  pace 
with  the  development  of  other  parts  of  the  face.  Hence  the  new 
structure  must  be  made  large. 

When  no  external  auditory  meatus  is  seen,  the  surgeon  may 
search  for  it  by  dissecting  up  the  soft  parts  in  the  region,  where  the 
opening  is  expected  to  be  found  on  the  bone.  If  the  meatus  is  indi- 
cated by  a  dimple  or  sinus  in  the  skin,  the  bone  under  that  point  should 
be  the  seat  of  exploration.  A  racquet  shape  flap  raised  over  the 
suspected  opening  in  the  bone  is  probably  as  good  an  exposure  as  any. 
If  the  bony  canal  is  found,  it  may  be  enlarged  carefully,  if  necessary, 
and  its  wall  smoothed  with  a  burr  or  other  instrument,  driven  with  the 
hand  or  a  surgical  engine.  Its  interior  may  be  lined  with  the  flap 
of  skin  made  by  the  exploratory  incision.  A  tubular  canal  should  be 
made  from  this  flap  with  a  pedicle  and  used  to  give  a  cutaneous 
lining  to  the  auditory  canal.  It  is  difficult  to  construct  a  meatus 
which  will  not  become  closed  by  cicatricial  changes.  Mucous  mem- 
brane grafts  from  the  lower  lips  or  prepuce  might  be  used  to  line  the 
new  canal. 

Injuries  of  the  Auricle. 

The  external  ear  is  quite  often  the  seat  of  incised  and  lacerated 
wounds,  which  require  accurate  suturing  to  reproduce  the  normal 
outline.  Portions  of  the  organ  are  lost  not  infrequently  in  drunken 
brawls  by  biting.  The  auricle  may  be  torn  almost  completeh^  from 
the  skull  and  yet  be  easih^  restored  to  its  normal  appearance  by  a  few 
carefully  placed  stitches.  Aseptic  cleanliness  and  accurate  coapta- 
tion will  yield  unexpectedly  good  results.  Completely  detached  pieces 
should  be  cleansed  and  sutured  in  position,  even  when  some  time  has 
elapsed  since  the  receipt  of  the  injury.  Occasional  union  maj'  be  ob- 
tained even  in  such  cases,  by  keeping  the  replaced  fragment  warm  and 
sterile.  The  ears  of  prize  fighters  often  receive  injuries  which  result 
in  permanent  cicatricial  deformity.  Sexton  called  attention  to  the 
fact  that  the  statues  of  the  ancient  Greeks  show  a  familiarity  with  the 
characteristic  distortion  of  the  boxer's  ears. 

Sloughing  after  frostbite  or  burns  is  a  not  unusual  cause  of  auricular 
disfigurement.  Plastic  restorations  will  greath"  improve  the  appear- 
ance of  many  such  ears.  A  common  injury  in  this  region  is  laceration 
of  the  lobule  from  rings,  which  have  been  torn  out  of  the  ear  by  children 
grasping  at  the  trinket.     Such  fissures  and  the  congenital  cleft  seen 


160  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

at  times  in  the  lobule  may  be  closed  without  marked  scarring  by 
freshening  the  edges,  somewhat  as  in  harelip,  and  applying  sutures. 
A  similar  plastic  operation  is  necessary  after  the  removal  of  the  keloid 
growths  that  occasionally  result  after  piercing  the  ears  for  rings. 
Other  tumors  may  require  removal  of  a  considerable  part  of  the  auricle 
and  necessitate  plastic  reparations.  A  lobule  may  be  made  from  two 
crescentic  flaps  cut  from  the  cheek  near  the  ear,  properly  stitched  to- 
gether. A  fair  helix  may  be  constructed  from  a  flap  cut  from  the  skin 
above  the  ear.  Ingenuity  in  these  operations  is  capable  of  giving 
much  satisfaction  to  the  patient,  who  is  disconcerted  by  the  uncomely 
outline  of  his  ear.  Great  losses  of  tissue  may  demand  that  free  flaps, 
or  flaps  from  the  thigh  or  abdomen,  transported  by  means  of  the  hand 
as  a  carrier,  be  used  for  restoring  the  organ.  Pedunculated  flaps  may 
be  turned  up  from  the  shoulder  or  neck.  They  may  be  tacked  to  the 
side  of  the  skull  with  ordinary  carpet  tacks,  when  there  is  no  good 
integument  to  which  to  fasten  them  with  sutures. 

An  effusion  of  blood  beneath  the  perichondrium  may  occur  from 
injury  to  the  ear  and  cause  marked  chronic  deformity.  This  condi- 
tion, called  othematoma,  has  been  considered  of  frequent  occurrence 
among  those  mentally  unsound.  It  is  possible  that  the  condition  is 
at  times  non-traumatic;  but,  on  the  other  hand,  a  slight  injury  causing 
it  may  readily  have  been  forgotten.  The  usual  site  of  deformity 
from  such  a  swelling  is  on  the  front  of  the  auricle,  because  of  the  less 
absorptive  power  here  and  the  adherence  of  the  tissues  to  the  cartilages. 
The  tumefaction  may  disappear  by  absorption,  may  rupture  with 
discharge  of  its  contents,  or  may  be  followed  by  suppuration.  Oc- 
casionally necrosis  of  the  cartilage  with  secondary  distortion  from 
atrophy,  hypertrophy  or  disfiguring  contraction  happens. 

Aseptic  incision  to  evacuate  the  imprisoned  blood  before  the  con- 
dition becomes  chronic  would  seem  to  be  the  proper  surgical  treatment, 
though  this  method  of  treatment  has  been  deprecated  by  some  and 
preference  given  to  massage. 

Deformities  from  Cartilaginous  Defects. 

Sometimes  a  deficiency  of  rigid  cartilage  in  the  auricle  allows  it 
to  assume  an  abnormal  position,  creating  a  lop  ear.  At  other  times 
the  cartilage  may  become  buckled  or  bent  during  birth  or  soon  after- 
ward and  asymmetry  of  the  two  ears  result,  from  want  of  correction 
of  this  abnormality.  The  lack  of  cartilaginous  rigidity  may  perhaps 
be  compensated  for  by  inserting  shavings  of  cartilage  as  grafts, 
or  by  introducing  metallic   filigree  to  become  encysted  within  the 


DEFORMITIES  OF  THE  EXTERNAL  EAR 


161 


tissues  of  the  auricle.  Excising  a  semi-ellipse  of  skin  from  the 
back  of  the  ear  and  another  from  the  side  of  the  skull  and  stitching 
the  raw  surfaces  together  may  be  an  effective  operation  to  hold  the 
flaccid  pinna  in  good  position.  The  raw  surfaces  must  extend  down- 
ward, so  as  to  join  at  the  bottom  of  the  furrow  between  the  ear  and 
the  cranium.  Lop  ear  so  treated  may  need  in  addition  an  elliptical 
section  of  skin  and  a  piece  of  the  thin  cartilage  removed  from  the  upper 
and  back  portion  of  the  drooping  auricle. 

The  deformity  due  to  unnatural  bending  or  buckhng  backward 


Fig.  136. — Lop  ear.     {Author's  patient.) 

of  the  cartilage  may  be  remedied,  if  the  child  is  treated  while  j'-oung, 
by  bending  the  organ  in  the  opposite  direction  and  holding  it  there 
with  strips  of  adhesive  plaster  for  several  months.  A  spring,  going 
across  the  top  of  the  head  with  a  pad  to  press  on  the  ear  and  hold  it  in 
the  corrective  position,  would  answer  as  well.  If  the  deformity  is 
slight,  applications  of  collodion  would  by  contraction  prevent  the 
occurrence  of  the  deformity  and  hold  the  auricle  in  its  proper  shape. 
A  slight  operation  done  under  cocain  will  be  more  rapid  in  its  result.  This 
consists  in  an  incision  of  the  overlying  skin,  excision  of  a  wedge  of  the 
11 


162  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

cartilage  and  the  use  of  one  or  two  fine  sutures  to  hold  the  cartilages 
in  the  desired  position. 

Dr.  James  S.  Stone  says  that  prominent  ears  may  be  due  to  loss  or 
insufficiency  of  the  normal  angle  at  the  antihelix,  between  the  concha 
and  the  fossae  above  and  behind  it.  He  changes  the  shape  of  the 
cartilage.  The  site,  at  which  a  strip  of  cartilage  should  be  excised,  he 
determines  by  pressing  the  lop  ear  backward  into  proper  shape  with 


Fig.  137. — Incisions  for  correcting  lop  ear. 

his  fingers.  A  strip  of  skin  along  this  line  is  cut  from  the  back  of  the 
auricle  and  the  necessary  piece  of  cartilage  removed.  W.  H.  Luckett 
has  a  similar  operation. 

Flaring  and  Gigantic  Ears. 

Outstanding  ears,  even  when  not  of  unusual  magnitude,  are  a 
source  of  chagrin  to  the  person  on  whose  head  they  exist.  Great 
improvement  in  the  appearance  of  the  patient  may  be  made  by  means 
of  a  simple  operation.  The  angle  between  the  cranium  and  the  back 
of  the  auricle  must  be  reduced  so  that  the  pinna  is  held  permanently 
closer  to  the  head.  This  is  done  by  cutting  away  the  skin  and  super- 
ficial fascia  in  the  groove  between  the  head  and  the  ear  and  stitching 
the  organ  in  its  new  position.  The  wound,  so  made,  consists  of  a 
raw  surface,  which  is  a  semi-ellipse  on  the  cranium  and  a  similar 
semi-ellipse  on  the  back  of  the  ear.  The  two  halves  of  the  elliptical 
denudation  are  often  not  symmetrical,  nor  is  the  ellipse  always  true. 

It  is  necessary  to  vary  the  outline  of  the  denuded  area  to  insure  a 


DEFORMITIES  OF  THE  EXTERNAL  EAR 


163 


proper  reposition  of  the  auricle.  The  shape  of  the  ear  may  require 
that  the  ellipse  be  wider  at  its  upper  than  at  its  lower  portion.  Usually 
the  semi-ellipse  on  the  ear  should  be  broader,  I  think,  than  that  cut  on 


Fig.  138. — Tumor  of  lobule  of  ear. 


Fig.  139. — Method  of  constructing  new  lobule 
after  excision  of  tumor. 


Fig.   140. 


Fig.   141. 


Fig.   142. 


Figs.  140,  141  and  142.- — Another  method  of  constructing  a  lobule  after  its  excision 

for  tumor. 


the  cranium.  The  upper  end  of  the  eilliptical  wound  should  curve 
around  the  top  of  the  concha.  Where  the  pinna  needs  to  be  drawn 
closest  to  the  head  the  width  of  the  excised  part  of  the  skin  should  be 


164 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


greatest.  A  quite  large  area  of  skin  and  fascia  should  be  removed  and 
some  of  the  auricular  cartilage  should  be  cut  out.  Unless  a  narrow 
strip  of  cartilage  is  removed  in  the  line  of  the  proposed  bending,  its 
resiliency  will  probably  make  the  operation  inefficient,  and  the  de- 
formity will  recur.  Perforation  of  the  skin  on  the  front  of  the  ear 
should  be  avoided.  This  is  generally  possible,  although  the  integu- 
ment in  front  is  mere  adherent  to  the  cartilage  than  is  that  on  the  back 
of  the  organ. 


Fig.   143. 


-Prominent  ear  in  which  the  deformity  is  due  to  loss  of  normal  angle 
at  the  anti-helix.       (J .  S.  Stone.) 


A  few  buried  catgut  sutures  sometimes  may  be  used  near  the  bot- 
tom of  the  cranio-auricular  angle.  They  are  not  usually  necessary. 
None  should  be  used  for  the  cartilage.  Silkworm  gut  or  silk  makes 
satisfactory  stitches  to  unite  the  edges  of  the  elliptical  denudation. 
By  the  insertion  of  the  sutures  in  an  oblique  direction  the  long  axis 
of  the  auricle  may  be  somewhat  changed.  Care  should  be  taken  to 
make  the  two  ears  match  in  position  and  general  appearance.  A 
marked  change  is  made  in  the  patient's  appearance  by  a  successful 
operation;  and  ears  that  previously  were  considered  much  too  large 
seem  to  have  been  diminished  in  size.     As  this  operation  is  done  only 


DEFORMITIES  OF  THE  EXTERNAL  EAR 


165 


for  a  cosmetic  effect,  it  will  frequently  be  found  that  a  patient,  who 
has  submitted  to  operation  because  of  a  desire  to  correct  large  flaring- 
ears,  will  be  satisfied  without  any  actual  change  in  the  size  of  the  auricle. 
It  is  the  unusually  wide  angle  between  the  cranium  and  the  external  ear 
which  often  causes  the  uncomeliness  that  attracts  attention. 

It  may  be  wise  for  a  patient  to  wear  a  bandage  or  a  close  fitting 
cap  over  the  ears  at  night  for  awhile  after  operation,  until  the  scar 
tissue  at  the  seat  of  operation  becomes  firm.     Three  or  four  weeks 


Fig.  144. — Prominent  ear.  The  deformity  due  to  loss  of  normal  angle  at  the  anti-helix  is  done 
away  with  by  restoring  the  angle.  Cure  should  consist  in  excising  skin  and  a  strip  of  cartilage 
on  posterior  surface.      (J.  (S    Stone.) 

should  be  sufficient  time  for  this  precaution.  Slight  degrees  of  out- 
standing ears  in  young  children  may  be  corrected  by  wearing  caps  or 
springs  on  their  ears  at  night  for  long  periods.  The  caps  should  not 
interfere  with  the  growth  of  the  head. 

It  has  been  said  that  operation  for  cosmetic  reasons  is  not  needed 
unless  the  cranio-auricular  angle  exceeds  50°.  The  operation  is  so 
successful  in  decreasing  the  apparent  size  of  large  ears  and  so  free 
from  danger  or  a  long  convalescence  that  such  a  rule  seems  valueless. 

Another  method  of  operating,  proposed  by  Duell,  consists  in 
drawing  the  external  ear  back  nearer  the  head  bv  means  of  a  hori- 


166 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


I'iG.  145. — Method  of  relieving  the  condition  called  cat's  auricle. 


Fig.  1  4  6.  —  KoUe's 
method  of  curing  flaring 
ears.  Dotted  lines  show 
amount  of  cartilage  to  be 
removed. 


Fig.  147. — ^Incisions  for  lessening  size 
of  gigantic  ears. 


Fig.    148. — Kolle's    method    of   reducing 
large  ears. 


Fig.   149. — Kolle's  method  to  put 
the  scar  in  helix  nearer  the  hair. 


DEFORMITIES  OF  THE  EXTERNAL  EAR 


167 


zontal  strap  of  integument,  cut  from  the  posterior  surface  of  the  ear 
and  slipped  under  a  vertical  bridge  of  skin,  which  has  been  made  on 
the  cranium  just  behind  the  cranio-auricular  groove.     The  cutaneous 


Fig.  150. — Gersuny's  method  of  repairing  auricle  when  necessary  to  excise  tumor 
involving  helix. 

surface  of  the  integumentary  strap  is  made  raw  where  it  lies  under 
the  bridge.  Its  distal  end  is  fixed  to  the  scalp  by  stitching  it  into  a 
quadrilateral  wound  made  by  excising  a  piece  of  the  scalp  just  large 


Fig.   1.51. — Gersuny's  method  when  part  to  be  removed  is  lower  do\^Ti  in  helix. 


enough  to  receive  it.  Sutures  are  employed  also  to  hold  the  vivified 
surface  of  the  strap  to  the  inferior  surface  of  the  l^ridge  of  skin,  under 
which  it  has  been  slipped. 


168  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

Exceedingly  large  ears  may  require  operation  because  of  their 
unsightliness.  If  they  are  not  flaring  or  if  the  operation  for  flaring 
ears  is  not  capable  of  reducing  their  apparent  bulk  sufficiently,  the 
bulk  of  the  ear  should  be  lessened  by  excision  of  cartilage  and  integu- 
ment. A  V-shaped  portion  of  the  entire  thickness  of  the  auricle, 
with  its  base  at  the  external  margin  of  the  helix,  should  be  cut  out. 
Careful  suturing  will  restore  the  general  outline  and  maintain  the  regu- 
larity of  the  natural  elevations  and  depressions.  The  operation  of 
Parkhill  probably  permits  a  more  perfect  restoration  of  the  surface  of 
the  auricle.  By  it  a  crescentic  piece  is  cut  out  of  the  center  of  the  pinna 
with  a  tongue-like  process  extending  from  the  convex  border  of  the 
crescent  to  the  edge  of  the  helix. 

Instead  of  excising  a  tongue  with  parallel  margins  from  the  outer 
part  of  the  auricle,  a  wedge  of  cartilage  and  skin  may  be  removed.  This 
modification  permits  a  more  extensive  diminution  of  the  circumferen- 
tial part  of  the  pinna  than  the  suggestion  of  Parkhill.  The  position 
and  size  of  the  crescent  and  the  wedge  to  be  cut  from  the  gigantic  ear 
must  be  determined  with  care.  They  must  vary  with  the  situation  of 
the  over-growth  of  the  auricular  structures. 

When  portions  of  the  helix  and  the  adjacent  tissue  of  a  normal 
ear  have  been  lost  by  wounds  or  gangrene  or  removed  in  excising 
tumors,  the  organ  may  be  constructed  by  using  incisions  similar  to 
those  just  figured.  The  result  will  be  a  smaller  though  shapely  ear. 
The  opposite  ear  may  then  be  cut  down  in  size  by  the  same  methods, 
to  match  the  i-econstructed  one. 


CHAPTER  XIII. 
DEFORMITIES  OF  THE  NOSE. 

There  may  be  complete  absence  of  the  external  nose.  In  the  case 
which  I  saw  some  years  ago  with  Dr.  Kercher,  no  evidence  of  an  ex- 
ternal nose  was  present.  The  infant,  which  died  a  few  days  after 
birth,  had  double  harelip  and  double  cleft  palate;  there  were  no 
nostrils;  and  no  cartilaginous  or  bony  nose  projected  from  the  face. 
The  space  between  the  line  of  the  eyes  and  the  upper  lip  was  practically 
level.     There   could   be  felt  with  the  finger-tip  through  the  smooth 


Fig.   152. — Dr.  Kercher's  case  of  congenital  absence  of  nose. 


skin  of  the  nasal  region  a  slightly  elevated  ridge  in  the  bony  structures 
of  the  face.  The  child  was  otherwise  well  formed  except  that  it  had, 
if  I  remember  correctly,  club  feet. 

Probably  the  most  common  congenital  deformity  of  the  nose  is  the 
flattened  ala  that  often  accompanies  a  cleft  of  the  upper  lip.  The  cor- 
rection of  this  error  in  development  has  been  discussed  in  the  chapter 
on  Harelip.  The  operative  treatment  of  the  nasal  distortions,  due  to 
a  displaced  intermaxillary  bone  in  cases  of  harelip,  has  been  mentioned 
in  the  same   place,    and   their   correction   is   there   described.     The 

169 


170 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


deformity  in  these  instances  is  apt  to  be  a  displaced  or  shortened 
columella,  or  a  deviation  of  the  septal  structures. 

Median  cleft  of  the  nose  is  a  congenital  malformation,  which  has, 
as  associated  conditions,  abnormal  breadth  of  the  face  and  lateral 
displacement  of  the  nasal  alse.  The  gap  left  by  the  absent  or  separated 
nasal  bones  has  been  closed  by  Nasse^  more  or  less  satisfactorily,  by 


Fig.  153. — Bent  nose. 


Fig.  154. — Twisted  nose. 


cutting  plates  of  bone  from  the  neighboring  processes  of  the  maxillae. 
These  were  moved  over  the  cleft,  and  with  the  adherent  soft  tissues 
were  superimposed  one  on  the  other.  The  diverging  plates  of  the  car- 
tilages were  united. 

An  incomplete  lateral  nasal  cleft  has  been  treated  by  thrusting 


Fis.    155. — Diagram  of  deviated  septa. 


into  the  groove  under  the  skin  a  wedge-shaped  piece  of  cartilage  taken 
from  the  ear. 

Crooked  nose  is  frequently  found  in  adults,  associated  with  ir- 
regular position  of  the  septum,  which  the  patient  does  not  attribute 
to  injury  in  early  life.  These  nasal  deformities  are  doubtless  often 
the  result  of  unremembered  falls,  causing  fracture  or  dislocation  of 
the  framework  of  the  nose,   in  infancy   or   childhood.     Sometimes, 

^  "Bull's  Edition  of  Bergmann's  System  of  Practical  Surgery,"  vol.  i,  p.  439. 


DEFORMITIES  OF  THE  NOSE 


171 


however,  the  twist  in  the  external  nose  is  evidently  due  to  a  buckling 
of  the  triangular  cartilage  of  the  septum,  which  seemingly  has  resulted 
from  its  overgrowth.  The  cartilage  assumes  a  sigmoid  curve,  because 
the  space  between  the  floor  of  the  nasal  chambers  below  and  the  nasal, 
ethmoid  and  vomer  bones  above  and  behind  is  too  small  to  accom- 
modate the  cartilage.  The  lower  anterior  part  of  the  triangular 
cartilage,  covered  with  the  mucosa,  is  often  seen  in  such  deformities 


Fig.  156. — Saddle  nose. 


Tuberous  nose. 


Angular  nose. 


projecting  into  one  nostril,  just  behind  the  columella.  This 
is  due  to  a  spontaneous  luxation  of  the  cartilage  from  the  anterior 
nasal  spine.  As  a  consequence  of  the  cartilage  having  its  upper 
and    lower    borders    held   in   a   rigid    bony  frame,  it    buckles   and 


Fig.   157. — Fetterolf  rasp  for  dividing  nasal  septum. 

causes  a  twist  or  bend  in  the  more  or  less  plastic  external  nose. 
It  is  probable  that  there  is  some  relation  between  these  sigmoid 
deflections  of  the  cartilaginous  septum  of  the  nose  and  imperfect 
widening  of  the  arch  of  the  roof  of  the  mouth.  A  high  arch  of  the 
hard  palate  necessarily  lessens  the  vertical  diameter  of  the  nasal 
chambers. 

Traumatic  deflections  of  the  septum  from  fractures  are  more  apt 
to  be  angular.  Spontaneous  deviations,  are  usually,  I  think,  curved. 
Deflections  from  injuiy  are  often  associated  with  cartilaginous  or  bony 
outSTowths  alone-  the  line  of  fracture  or  luxation.     If  the  fracture 


172 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


has  been  comminuted  with  much  displacement,  both  nostrils  may 
become  entirely  filled  with  masses  of  bone  and  cartilage.  I  once  had 
to  quarry  through  obstructions  of  this  kind  with  a  chisel,  in  order  to 
restore  the  patency  of  the  nares. 


Fig.   158. — Different  forms  of  intra -nasal  splints. 

Occlusion  of  the  nostrils  in  early  life  may  cause  the  patient  to  be 
a  constant  mouth  breather.  As  a  result  of  the  constantly  open  mouth, 
the  teeth  are  improperly  developed,  a  proper  articulation  of  the 
teeth  is  never  obtained  and  deficiency  in  the  size  of  the  lower  jaw 
may  affect  greatly  the  appearance  of  the  countenance. 


Fig.  159. — Author's  method  of  using  pins  to  hold  fractured  or  incised  quadrangular  cartilage  or 

bony  septum  in  position. 

In  septal  distortions  bridges  of  cartilage  or  bone  may  extend 
across  from  the  septum  to  the  inferior  turbinal.  Enchondromas 
with  bony  bases  are  quite  frequent  at  the  base  of  the  septum.  Some- 
times the  septum  instead  of  having  a  sigmoid  curve  from  above 
downward  as  shown  in  the  diagram,  has  a  double  curve  in  the  antero- 


DEFORMITIES  OF  THE  NOSE 


173 


posterior  direction.  Then  respiration  is  imperfect  in  the  front  of 
one  nostril  and  in  the  back  of  the  other.  Usually  the  nasal  chamber 
on  the  concave  side  of  the  deviated  septum  is  abnormally  patent, 
and  that  on  the  opposite  side  more  or  less  obstructed.     The  deviated 


Fig.  160. — Sunken  nose  of  syphilis. 


Fig.  161. — Nasal  deformity  from  specific  necrosis. 


septum  may  be  unusually  thick  with  a  great  degree  of  overgro^vth  on 
one  side.  Then  there  may  be  no  unusual  patency  on  either  side. 
Such  cases  need  the  redundant  tissue  to  be  pared  away  on  both 
sides,  to  restore  and  maintain  proper  ventilation  of  both  nasal  cavities. 


Fig.  162. — Nasal  deformity  from  specific  necrosis. 


Fig.  163. — Nasal  deformity 
from  specific  necrosis. 


In  correcting  deformities  of  the  external  nose,  associated  with  con- 
genital or  acquired  deviations  of  the  septal  cartilage  and  bones,  it  is 
essential  that  the  internal  structures  be  restored  to  their  normal 
position,  or  their  injurious  influence  on  the  shape  of  the  nose  removed. 


174 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Proper  provision  should  at  the  same  time  be  made  for  free  respiration 
through  both  nostrils.  This  respiratory  freedom  should  be  obtained 
even  if  a  permanent  perforation  in  the  septum  is  left  by  the  operative 
work.     Investigation  is  required  to  determine  the  possibility  of  the 


Fig.  164. — Nasal  deformity  from  specific  necrosis. 

imperfect  breathing  being  partly  due  to  hypertrophy  of  the  faucial 
or  pharyngeal  tonsils.  If  these  lesions  exist,  they  should  be  given 
appropriate  treatment  in  addition  to  that  required  to  straighten  the 
nose  and  provide  open  air-ways  through  it. 


Fig.  165. — Syringe  for  injection  of  paraffin,  and  small  chisels  for  nasal  surgery. 

The  tuberous  nose,  which  has  a  bulbous  end  from  hypertrophy  of 
the  lobe  or  a  tumor  situated  therein,  may  be  cured  by  excising  a  V- 
shape  portion  and  re-uniting  the  wound  surfaces  with  fine  linen 
or  silk  sutures.     The  bifid  nose  may  be  corrected  by  a  similar  op- 


DEFORMITIES  OF  THE  NOSE 


175 


eration.     Here,  however,  very  little  tissue  is  to  be  removed,  for  the 

object  of  the  incisions  is  to  simply  freshen  the  surfaces  of  the  cleft, 

in  order  that  they  may  unite  when  brought  together  with  the  stitches. 

The  angular  nose  demands  removal  of  the  lower  margin  of  the  nasal 


0-^l>it 


Othlt 


Fig.  166. — Diagram  of  cartilages  of  the  nose  (anterior  view). 

bones  at  the  internasal  suture  and  the  prominent  cartilage  just  below  this 
point.  An  incision  is  made  on  the  nasal  bridge  with  a  sharp  thin 
knife;  and  the  bone  and  cartilage  are  then  shaved  off  with  a  small  sharp 
chisel,  aided  perhaps  with  a  scalpel.     It  is  probaby  better  to  raise  a 


ifv-p1.rljiti.y3l 


l^essonoiL  c!i.rtiU9<iS 


^ice^ 


<^art  of  Scftuni. 


Fig.  167. — Diagram  of  lateral  cartilages  of  the  nose. 

flap  of  skin,  with  its  convex  border  running  down  one  side  of  the  dorsum, 
than  to  work  through  a  linear  cut  in  the  median  line  of  the  nose.  The 
flap  gives  more  room  than  a  straight  incision  and  permits  easy  access 
to  the  whole  width  of  the  dorsum.  The  scar  is  less  likely  to  be  seen 
than  that  left  by  the  median  cut. 


176  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

The  hooked  nose  may  be  altered  by  cutting  or  chiseling  away  the 
hump.  The  lower  edge  of  the  nasal  bones  may  need  to  be  depressed; 
and  this  may  require  dissecting  out  a  piece  of  the  septal  cartilage 
beneath  that  border.  The  skin  incision  to  reach  the  structures  to  be 
removed  would  not  be  conspicuous.  Instead  of  cutting  out  a  piece 
of  the  septal  cartilage,  that  part  of  the  septum  may  be  divided  intra- 
nasally  just  beneath  the  lower  border  of  the  nasal  bones.  They 
can  then  be  dejDressed. 

Instead  of  chiseling  away  the  hump  made  by  the  nasal  bones,  on 
the  dorsum,  a  narrow  central  strip  may  be  cut  out  with  a  tiny  tre- 
phine, a  chisel  or  a  rasp,  driven  along  the  internasal  suture.  As  a 
second  step  the  nasal  bones  are  to  be  cut  loose  from  the  frontal  and 
maxillary*  bones,  and  pushed  together  at  the  middle  line,  so  as  to  make 
a  flat  arch  instead  of  the  previous  high  one. 


p'ph,e,-no  i  claX 
jSi-tius 


Ite-rygeiel 

Xo-ocess 


7^i.1i.iXl.  Jroeesff 


Fig.   168. — Diagram  of  bony  and  cartilaginous  septum  of  the  nose. 

The  drooping  tip,  which  disfigures  some  noses,  may  be  corrected  by 
removing  submucously  a  triangular  piece  of  the  quadrangular  septal 
cartilage.  The  base  of  the  triangle  excised  should  be  just  below  the 
cartilaginous  dorsum  of  the  nose  and  the  apex  should  point  downward 
and  backward.  The  drooping  tip  or  lobule  may  then  be  pressed  up- 
ward and  retained  in  this  new  position  for  some  days  with  adhesive 
plaster.  If  necessary,  some  of  the  external  skin  and  the  underlying 
cartilage  may  be  excised,  as  in  Joseph's  operation  for  gigantism  of  the 
nose. 

A  drooping  tip  has  been  supported  by  inserting  a  piece  of  cartilage, 
excised  submucously  from  the  back  of  the  quadrangular  cartilage, 
between  the  two  layers  of  mucosa  behind  the  columella.  I  have  used 
for  this  purpose  a  peg-shape  piece  of  cartilage  cut  from  a  costal  car- 
tilage. 

The  bent  or  twisted  nose,  resulting  from  septal  deviation  or  fracture 


DEFORMITIES   OF  THE   NOSE  177 

of  the  bony  and  cartilaginous  framework  of  the  organ,  recfuires  a  more 
extensive  operation.  The  septum  should  be  straightened  by  incision, 
with  knife  or  the  Fetterolf  rasp,  fracture  with  forceps,  multiple  in- 
cisions with  the  stellate  punch,  submucous  resection  or  such  other 
procedures  as  may  be  needed.  Cartilaginous  and  bony  masses,  due 
to  irregular  union  of  fractures  or  dislocations,  must  be  removed. 
Then  the  bones  and  cartilages  remaining  in  abnormal  relations  with 
the  surrounding  parts  must  be  freed  by  subcutaneous  and  submucous 
cuts  with  small  saws,  knives  and  tenotomes. 

The  soft  parts  may  be  detached  from  the  bones  very  freely  by  means 


vA^asal 


Fig.  169. — Diagram  showing  lines  of  fracture-dislocation  of  septum  from  blows  on  iront  of  nose. 

{Modified  from  Chevallet.) 

of  a  tenotome  making  a  tunnel  through  the  skin  at  the  lower  end  of  the 
lobe  or  on  the  lower  surface  of  the  alse.  It  may  be  introduced  into  the 
nostril  and  thrust  through  the  mucous  membrane,  in  order  to  reach  the 
site  at  which  the  surgeon  thinks  necessary  to  divide  the  tissues  sub- 
cutaneously.  A  narrow  saw  or  chisel  may  be  thrust  along  a  channel 
thus  created,  and  used  to  separate  the  nasal  bones  from  the  nasal 
process  of  the  superior  maxilla.  Access  may  be  obtained  to  the  nasal 
structures  also  by  raising  the  upper  lip  and  going  through  the  mucous 
membrane  of  the  mouth.  A  chisel  may  be  introduced  thus  to  cut 
the  septum  from  the  floor  of  the  nose.  After  the  external  nose  has  been 
made  mobile  by  these  extensive  subcutaneous  detachments  it  is 
displaced  laterally  or  forced  into  a  straight  and  symmetrical  position 
and  held  there  by  intra-nasal  splints  or  steel  pins.     Sometimes  incisions 


178  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

in  the  skin  may  be  demanded  to  allow  use  of  the  saw  or  chisel  for  sep- 
arating the  nasal  bones  from  the  frontal  bone  or  to  split  the  nasal 
bones  from  each  other.  The  wounds  made  for  the  entrance  of  these 
small  instruments  will  leave,  however,  scars  that  will  not  be  very  notice- 
able, and  hence  they  are  not  very  objectionable. 

To  restore  the  crooked  nose  to  its  natural  shape  requires  that  all 
resiliency  be  taken  from  the  distorted  structures.  The  greater  part  of 
the  triangular  cartilage  and  the  vomer  may  be  removed  submucously 
by  cautious  and  painstaking  separation  of  the  muco-periosteum  on 


^A5A^ 


Fig.  170. — Diagram   showing    displacemeat   from    fracture-dislocation    of    septum     and   latera 
cartilages  of  nose.      (Modified  from  Chevallet.) 

both  sides  of  the  septum.  The  surgeon  must  work  to  have  the  organ 
very  flexible  and  its  bones  and  cartilages  and  attachments  under  his 
control.  It  should  then  be  twisted  or  moulded  with  the  fingers  into  a 
somewhat  over-corrected  position,  before  the  retaining  pins  or  splints 
are  adjusted.  These  mechanical  supports  should  be  used  for  about 
a  week  or  ten  days.  The  splints  should  be  removed  from  the  nostrils 
every  day,  and  put  back  after  the  nasal  chambers  have  been  flushed 
out  or  sprayed  with  a  mild  aseptic  or  antiseptic  solution.  Sterile 
normal  salt  solution,  the  compound  solution  of  sodium  borate,  and 
liquor  antisepticus  are  useful  washes  for  this  purpose.  When  pins 
are  used  for  retention  of  the  replaced  nasal  structures,  they  do  not 
need  to  be  disturbed  when  the  nasal  chambers  are  irrigated  or  sprayed. 
Local  anesthesia  with  cocaine  is  sufficient  in  mild  cases  of  deformity 
of  the  septum;  but  in  more  extensive  operations  general  anesthesia  is 


DEFORMITIES  OF  THE  NOSE 


179 


necessary.  The  procedure  is  a  bloody  one  when  the  deformit}'  is 
marked.  Adrenahne  sohition  may  be  applied  to  lessen  bleeding. 
To  prevent  blood  entering  the  trachea  the  patient  may  lie  on  his  back, 
with  the  head  thrown  far  backward;  or  on  his  side,  so  that  the  blood 
will  mostly  collect  in  the  lower  side  of  the  mouth  and  pharynx.  If 
the  surgeon  prefer,  he  may  stop  up  the  pharynx  l^ehind  the  soft  palate 
with  a  gauze  or  marine  sponge  held  with  a  pair  of  long  locked  forceps 
introduced  through  the  mouth,  which  is  held  open  Avith  a  gag. 

The  errors  likelv  to  l^e  committed  in  straightening  crooked  noses  are 


Fig.   171. — Diagram  of  method  of  plugging  nose  for  bleeding  after  nasal  operations,  bj'  using 
sea-sponges  threaded  on  a  stout  ligature. 


insufficient  division  of  the  distorted  structures  and  the  use  of  too  little 
force  when  an  effort  is  made  to  force  the  nose  into  its  normal  relation 
with  the  face. 

A  strong  forceps,  similar  to  that  devised  by  Adams  to  break  the 
septum,  is  a  very  useful  instrument  for  the  operator  to  employ  when 
he  wishes  to  wrench  the  crooked  nose  from  its  abnormal  position  and 
straighten  it.  He  grasps  the  mobilized  septum  in  the  blades  of  this 
instrument  and  replaces  it  with  one  hand,  while  he  twists  the  pro- 
jecting nose  into  the  proper  position  with  the  fingers  of  the  other  hand. 

External  splints  have  been  applied  after  these  operations,  but  they 
do  not  =!eem  to  be  needed  if  the  work  of  replacement  has  been  thor- 
oughly done  and  pins  or  intra-nasal  splints  have  been  properly  applied. 


180)  i  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

The  saddle  shape  nose  probably  arises  from  a  want  of  proper 
development  of  the  bones  and  cartilages  forming  the  septum.  It  is 
a  common  feature  in  some  races  of  men.  It  may  occur  in  inherited 
syphilis.  This  concave  dorsum  is  a  cosmetic  blemish  if  it  is  greater 
than  comports  with  the  configuration  of  the  other  features  of  the  face. 

It  is  a  different  condition  from,  and  very  much  less  conspicuous  and 
disfiguring  than,  the  horrid  sunken  nose  following  syphilitic  necrosis 
of  the  septum  and  other  intra-nasal  structures.  In  the  latter  condi- 
tion the  middle  of  the  dorsum  of  the  nose  sinks  into  the  nasal  chambers 
from  lack  of  necessary  support.  As  a  result  there  is  produced  a  deep 
transverse  furrow  between  the  bony  bridge  of  the  nose  and  its  lobe;  the 
tip  of  the  nose  is  drawn  upward  from  the  line  of  the  mouth  and  the 
nostrils  no  longer  lie  in  a  horizontal  plane,  but  look  directly  forward. 

In  marked  saddle  nose  a  piece  of  bone  or  celluloid  cut  to  accu- 
rately fill  the  hollow  may  be  slipped  through  an  incision  in  the  skin, 
which  has  been  previously  undermined,  and  left  permanently  in  that 
position.  The  upper  surface  of  the  foreign  substance  is  flat,  the  lower 
convex.  Thus  the  line  of  the  dorsum  is  changed  and  the  saddle  nose 
converted  into  one  of  a  Grecian  type.  The  shape  to  be  given  the  bone 
or  celluloid  is  determined  by  making  a  model  of  the  surface  of  the 
disfigured  nose.  This  is  done  by  means  of  a  plaster-of-Paris  impres- 
sion or  mould  in  the  manner  adopted  by  dentists  for  making  dentures. 

This  method  of  altering  the  contour  has  been  superseded,  however, 
by  the  use  of  paraffin  injections.  Paraffin  which  has  a  melting-point 
of  about  105°  to  110°  F.  is  sterilized  by  heat  and  injected  while  fluid 
with  a  sterilized  and  heated  syringe  under  the  skin,  so  as  to  fill  the 
hollow  in  the  dorsum  of  the  nose.  A  large  hypodermic  syringe,  such 
as  is  used  in  veterinary  surgery,  is  all  that  is  necessary.  The  ordinary 
needles  used  for  hypodermatic  injections  are  of  too  small  a  caliber.  A 
few  drops  of  the  heated  and  therefore  fluid  paraffin  should  be  injected 
beneath,  not  into,  the  skin;  and,  while  still  soft,  this  waxy  substance  is 
moulded  with  the  operator's  fingers.  It  promptly  solidifies  as  it  loses 
heat,  and  retains  the  form  given  it  by  the  surgeon.  The  skin  of  the 
nose  must  be  sterilized  before  the  puncture  is  made  and  the  operator's 
hands  must  be  sterile.  During  the  injection  the  fingers  of  an  assistant 
should  be  pressed  firmly  against  the  sides  of  the  nose  to  confine  the 
liquid  paraffin  to  the  dorsum.  If  this  be  neglected,  the  injected 
material  will  escape  into  the  subcutaneous  tissues  of  the  cheeks  near 
the  eyes  and  produce  great  disfigurement. 

Only  five  to  ten  minims  should  be  injected  at  first,  according  to  the 
depth  of  the  hollow  to  be  filled.  The  needle  should  then  be  withdrawn 
and  the  effect  of  the  modeling  with  the  operator's  fingers  observed. 


[DEFORMITIES  OF  THE  NOSE  181 

If  the  paraffin  hardens  too  rapidly,  hot  cloths  may  be  laid  upon  the 
nose  and  sufficient  softening  be  thus  obtained  to  permit  a  still  further 
change  in  form  by  digital  pressure.  This  secondary  modeling  is  not 
possible,  if  the  melting-point  of  the  jaaraffin  be  over  about  105°  F.  If 
examination  shows  that  an  insufficient  quantity  of  the  melted  paraffin 
has  been  injected,  a  few  more  minims  are  deposited  by  inserting  the 
needle  in  another  place.  '-This  process  may  be  repeated  a  number  of 
times.  The  portion  of  skin  raised  is  varied  by  changing  the  direction 
and  depth  of  the  needle  point.  Speedy  work  is  required,  because  the 
IDaraffin  soon  hardens  within  the  needle.  This  renders  further  injection 
impossible  unless  the  syringe  and  its  needle  are  dropped  into  boiling 
water  again  for  a  few  moments.  A  rather  large  syringe  with  a  screw 
nut  to  gradually  force  down  the  piston  is  very  convenient.  It  retains 
the  heat  longer  than  a  smaller  syringe  and  enables  the  surgeon  to 
force  cool  and  semi-solid  paraffin  into  the  tissues. 

The  operation  is  rather  painful,  but  is  readily  borne  by  the  average 
patient  without  anesthesia.  I  have  always  avoided  local  anesthetics 
as  being  inapplicable.  General  anesthesia  may,  of  course,  be  used 
if  desired.  The  punctures,  if  made  with  aseptic  precautions,  need  no 
dressing.  The  patient  should  bathe  the  nose  frequently  with  cold 
water  or  apply  cold  compresses  to  allay  the  inflammatory  reaction 
clue  to  the  effect  of  the  heat  and  tension  on  the  soft  tissues.  In  a  few 
days  the  redness  and  feeling  of  pressure  subside. 

It  is  much  better  to  introduce  too  little  paraffin  than  to  run  the 
risk  of  depositing  too  large  a  mass.  It  is  easy  to  rei3eat  the  procedure 
in  a  few  days  or  weeks,  if  after  the  lapse  of  that  time  the  inadequacy 
of  the  operation  is  evident.  To  remove  paraffin  causing  an  over- 
correction necessitates  a  cutting  operation  and  may  leave  undesirable 
scarring. 

Suppuration  from  imperfect  asepsis  or  any  cause  is  greatly  to  be 
deprecated.  It  should  be  treated  by  incisions  to  give  early  vent  to  the 
pus.  Occasionally  the  inflammatory  reaction  is  so  severe  that  sup- 
puration seems  imminent.  A  couple  of  days  observation  may  show 
that  the  swelling  was  due  to  exudate  that  is  being  slowly  absorbed 
without  the  formation  of  pus.  To  establish  the  absence  of  pus  may 
require  an  exploratory  puncture. 

Embolism  of  the  vessels  of  the  retina  is  said  to  have  occurred  from 
particles  of  paraffin  entering  the  circulation.  As  a  result  blindness  has 
resulted.  This  unusual  accident  should  be  thought  of  as  a  possibility. 
It  must  be  very  rare.  Pressure  by  the  assistant's  fingers  along  the 
side  of  the  nose  to  confine  the  fluid  paraffin  to  the  dorsum  may  perhaps 
tend  to  prevent  the  occurrence  of  this  calamity. 


182  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

When  the  nose  is  cicatricial  it  is  difficult  to  force  the  liquid  paraffin 
into  the  fibrous  tissue  covering  the  bones  of  the  nasal  bridge.  Open- 
ings may  then  be  made  with  a  small  tenotome  and  the  skin  under- 
mined to  make  a  cavity  to  receive  the  wax-like  material.  This  opera- 
tion is  a  more  difficult  one  than  that  just  described  and  requires  more 
care  and  skill. 

The  paraffin  is  best  melted  and  sterilized  in  a  small  glass  vessel 
placed  in  a  hot-water  bath.  The  water  in  the  bath  may  then  be  used 
to  sterilize  and  keep  warm  the  syringe  and  needles.  Small  forceps  and 
pads  of  gauze  are  used  to  handle  the  hot  instruments.  The  patient's 
face  and  eyes  should  be  protected  from  possible  burning  from  contact 
with  the  syringe  or  with  hot  drops  of  paraffin  escaping  from  it,  if  very 
hot  paraffin  is  used. 


Fig.    172. — -Dr.  Jacques  Joseph's  Fig.    173. — Dr.  Jacques  Joseph's 

method  of  reducing  the  size  of  a  giant  method  of  reducing  the  size  of  a  giant 

nose.      First   step.      Shaded    portion  nose.      Second  step.     Shaded  portion 

shows  tissue  excised.  is  that  removed. 

The  sunken  nose  of  tertiary  syphilis  is  the  result  of  necrosis  of  the 
bones  and  cartilages  forming  the  framework  or  scaffolding  of  the 
external  organ.  The  loss  of  these  devitalized  structures  causes  the 
nose  to  fall  inward  and  acquire  internal  cicatricial  adhesions.  The 
general  type  of  the  deformity  has  been  described  when  discussing  saddle 
nose,  with  which  it  is  contrasted.  The  degree  of  the  deformity  and  its 
detailed  peculiarities  vary  with  the  amount  of  internal  necrosis.  There 
is  often  some  loss  of  the  external  parts  of  the  nose  as  well  as  of  the 
septum  and  turbinates. 

Great  improvement  is  possible  in  these  deformities.  The  methods 
of  operating  will  be  discussed  when  the  more  formal  rhinoplastic  opera- 
tions are  described  later. 


DEFORMITIES  OF  THE  NOSE 


183 


Gigantism  of  the  Nose. 

A  very  large  nose  may  be  diminished  in  size  by  the  procedure  of 
Dr.  Jacques  Joseph  of  Berhn.  He  reduces  the  great  width  of  the 
organ  and  the  unusually  large  nares  by  the  removal  of  an  inverted 
V-shape  jDiece  of  skin  and  cartilage  on  the  top  and  sides  of  the  nose. 
The  projection  of  the  nose  forward  is  lessened  by  cutting  and  chiseling 
away  a  sufficient  amount  of  the  bone  and  cartilage  of  the  bridge  or 
anterior  surface  of  the  organ. 

As  a  third  step  the  septum  is  shortened  by  incising  a  wedge  of 
tissue  with  its  base  in  front  and  the  point  of  the  wedge  directed  obliquely 
downward  and  backward.  A  shapely  nose  of  much  less  bulk  is  then 
constructed  by  suturing  the  parts  in  the  same  relative  positions  that 


J^ 


X 


Fig.  174. — Dr.  Jacques  Joseph's  method 
of  reducing  size  of  a  giant  nose.     Third  step. 


Fig.  175. — Modifications  of  an- 
terior incisions  in  Joseph's  operation 
for  giant  nose  t  o  suit  varying 
deformities. 


they   held   before   the   removal  of  the  superabundant  tissues.     The 
entire  operation  is  done  at  one  sitting. 

Some  variation  in  the  lines  of  the  inverted  V  is  demanded  to  meet 
the  requirements  of  different  forms  of  nasal  gigantism.  In  some 
such  noses  it  is  the  dorsum  that  is  conspicuou.sly  large;  in  others  the 
lobule  or  alse  need  curtailins;. 


Epicanthus. 

The  peculiar,  broad  and  flattened  appearance  of  the  root  of  the 
nose,  seen  in  epicanthus,  where  the  skin  of  the  side  of  the  nose  en- 
croaches on  the  inner  canthus  of  the  eyes  is  remediable  by  operation. 


184 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


A  vertical  ellipse  of  integument  and  subcutaneous  fascia  is  dissected 
from  the  bridge  of  the  nose  at  its  root.  The  width  of  the  ellipse  must 
be  governed  by  the  extent  of  the  encroachment  of  the  integument  on 
the  palpebral  fissures.  The  widest  portion  of  the  ellipse  should  be  at 
the  level  of  the  inner  angle  of  the  palpebral  fissure.  Its  length  must 
vary  somewhat  with  the  degree  of  the  congenital  deformity.  Its 
upper  end  starts  in  the  skin  of  the  forehead.  The  skin  between  the 
nasal  wound  and  the  eyes  must  be  undercut,  so  that  it  will  slide  toward 
the  middle  line,  when  the  edges  of  the  ellipse  are  drawn  together  with 
the  sutures.  It  is  wise  in  cases  of  slight  epicanthus  to  delay  operation 
a  few  years  until  the  child's  nose  has  shown  the  probable  extent  of 


Fig.  176. — Monk's  method 
of  tunneling  with  scissors  or 
chisels  through  subcutaneous 
tissues  of  nasal  lobule. 


Fig.  177. — Arrow  head  excision  to  cure  deformity  of  epicanthus. 


its  development;  because  the  increasing  prominence  of  the  bony 
structures  of  the  bridge  may  cause  a  spontaneous  cure  of  the  unsightly 
appearance  at  the  inner  end  of  the  palpebral  fissure. 

When  epicanthus  is  met  with  in  adults  and  is  associated  with  saddle 
nose,  the  subcutaneous  injection  of  paraffin,  as  suggested  in  the 
treatment  of  saddle  nose,  will  elevate  the  integument  over  the  concave 
dorsum  of  the  nose  and  at  the  same  time  may  suffice  to  correct  the 
epicanthus.  Another  form  of  operation  is  by  an  arrow-head  excision 
of  skin. 

Fractures  and  Dislocations  of  Nasal  Structures. 

It  is  important  that  all  recent  injuries  of  the  nose  should  be  skil- 
fully treated  at  once,  in  order  that  deformity  from  unreduced  frac- 


DEFORMITIES  OF  THE  NOSE  185 

tures  or  dislocations  of  the  bones  and  cartilages  or  from  sloughing  or 
mal-apposition  of  the  soft  parts  may  be  averted.  Insignificant  hurts 
may  cause  displacements,  which  are  easily  reduced  at  the  time  but  apt 
to  leave  distortion  when  the  swelling  of  injury  has  subsided,  unless 
reduction  has  been  promptly  and  thoroughly  effected.  The  displace- 
ment once  corrected  does  not  readily  recur,  especially  if  the  parts 
are  supported  for  a  few  days  by  intra-nasal  plugs  or  tubular  splints; 
or  by  nasal  pins,  such  as  are  employed  in  maintaining  the  septum 
after  correction  of  its  deviations.  Accurate  adjustment  of  the  soft 
tissues  is  to  be  made  with  sutures,  when  lacerations  or  other  wounds 
have  been  sustained. 

The  vitality  of  the  parts  is  great,  because  of  the  abundant  blood 
supply.  Appalling  wounds  may  be  successfully  treated  Avith  a 
moderate  degree  of  deformity  only,  provided  that  a  careful  examina- 
tion of  the  internal  and  external  nasal  structures  is  made  and  judicious 
aseptic  or  antiseptic  restoration  is  accomplished  at  the  primary 
dressing. 

The  swelling  occurring  a  few  hours  after  a  nasal  traumatism  ob- 
scures the  condition  of  the  septal  and  other  bones  and  cartilages. 
Early  examination  with  the  head  mirror  and  probes  will  afford  much 
important  information. 

Blows  received  on  the  front  of  the  nose  are  liable  to  break  the 
cartilaginous  or  vomerine  septum  in  more  or  less  oblique  or  V-shaped 
lines.  The  front  fragment  is  then  forced  backward  or  backward  and 
downward,  so  as  to  slide  past  the  posterior  fragment.  It  is  this  over- 
lapping displacement  which  is  likely  to  be  overlooked  from  the  swelling 
and  bleeding  incident  to  the  injury.  As  a  result  the  bridge  of  the 
nose  is  found  later  to  be  depressed  and  one  or  both  nasal  chambers 
obstructed.  The  saddle  nose  so  produced  is  a  cosmetic  defect;  and 
the  interference  with  nasal  respiration  is  liable  to  induce  mouth  breath- 
ing with  its  deleterious  effect  on  the  shape  of  the  jaws. 

When  the  blow  is  more  severe,  it  may  fracture  the  nasal  bones, 
dislocate  them  from  the  ascending  process  of  the  maxilla  or  from 
the  nasal  spine  of  the  frontal  bone,  or  separate  the  internasal  suture. 
These  injuries  not  only  drive  the  bridge  of  the  nose  inward  and  cause 
flattening  or  a  saddle-like  appearance,  but  the  dorsum  of  the  organ 
is  widened  or  perhaps  deviated  laterally.  Combinations  of  injuries 
of  the  nasal  bones,  the  cartilaginous  dorsum,  and  of  the  septal  struc- 
tures give  rise  to  much  variation  in  the  degree  and  character  of  the 
distortion  of  the  nose. 

When  the  upper  lateral  cartilage  is  dislocated  from  the  lower 
border  of  the  nasal  bone  there  occurs  a  hollow  in  the  dorsum  of  the 


186  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

nose  at  about  the  junction  of  the  middle  and  the  lower  thirds.  It 
should  be  reduced  and  supported. 

The  triangular,  better  called  the  quadrangular,  cartilage  of  the 
septum  is  luxated  quite  often  from  the  perpendicular  plate  of  the 
ethmoid.  The  cartilage  is  shoved  backward  alongside  of  the  ethmoid 
part  of  the  septum.  Thus  the  cartilage  takes  an  oblique  position  and 
obstructs  both  nostrils;  one  with  its  posterior,  the  other  with  its 
anterior  portion.  It  may  be  dislocated  from  the  vomer,  or  the  vomer 
may  be  dislocated  from  the  maxillse. 

These  dislocations  should  be  recognized  and  reduced  before  swelling 
occurs.  The  finger  in  the  nares  is  a  useful  means  of  replacing  the 
displaced  structures.  Splints,  plugs  of  gauze,  a  cork,  or  pins  may  be 
used  for  retention. 

Fracture  of  the  nasal  bones  is  more  likely  when  the  force  comes 
from  the  side  than  otherwise;  hence  lateral  deviation  as  well  as  depres- 
sion is  common  in  nasal  injuries. 

When  displacement  from  fracture  or  dislocation  or  both  is  dis- 
covered by  a  carefully  and  systematically  conducted  examination, 
diligent  and  intelligent  efforts  should  at  once  be  made  to  restore  the 
osseo-chondral  framework  of  the  nose  to  its  normal  shape.  General 
anesthesia  may  be  necessary  to  secure  a  clear  understanding  of  the 
exact  nature  of  the  injury  and  to  effect  accurate  replacement.  Solu- 
tion of  cocaine  locally  may  be  sufficient.  When  bleeding  obscures 
the  view  adrenalin  may  be  added  to  it. 

The  normal  arch  of  the  nasal  bridge  is  narrow,  and  swelling  of  in- 
jured mucous  membrane  lessens  it.  Therefore,  only  a  narrow  in- 
strument, such  as  a  steel  probe  or  grooved  director  or  the  back  of  a 
nasal  saw,  can  be  thrust  under  the  broken  or  displaced  bones  of  the 
dorsum  to  aid  the  surgeon  in  restoring  the  contour.  Within  two  or 
three  days  after  the  receipt  of  injury  it  is  usually  not  difficult  to  mould 
the  fragments  into  place  with  the  fingers  of  one  hand,  while  such  an 
instrument,  introduced  through  the  nostril,  is  used  with  the  other 
hand  to  lift  the  fractured  parts  into  proper  relations  with  the  rest  of 
the  nose.  After  the  lapse  of  four  or  five  clays  such  manipulation  be- 
comes constantly  more  and  more  difficult,  because  of  the  rapid  union 
of  the  bones,  cartilages  and  mucous  membrane  in  abnormal  positions. 

The  broken  and  overlapped  septum  is  similarly  replaced  with  com- 
parative ease.  Its  anterior  portion  should  be  grasped  with  a  large 
forceps  with  flat  parallel  blades  like  the  Adams  forceps,  and  pulled 
forward;  at  the  same  time  the  posterior  angular  end  of  the  anterior 
fragment  should  be  tilted  upward  by  depressing  the  handle  of  the 
forceps.     This  maneuver  lifts  the  quadrangular  cartilage  and  any  at- 


DEFORMITIES  OF  THE  NOSE  187 

tached  portions  of  the  vomer  or  ethmoid  bones  up  into  place  and  gives 
support  to  the  nasal  bones  and  lateral  cartilages.  Depressions  in  the 
line  of  the  dorsum  of  the  nose  are  thus  eliminated.  Any  lateral  devia- 
tion of  the  broken  septum  should  be  corrected  at  the  same  time,  and 
thus  occlusions  of  the  nares  and  nasal  chambers  removed.  Internal 
nasal  splints,  or  pins,  or  perhaps  springs  or  pads  adjusted  to  the  out- 
side of  the  nose,  so  as  to  make  appropriate  pressure  may  be  needed  to 
maintain  the  corrected  position  of  the  injured  tissues.  The  last  named 
instruments  may  be  attached  to  head  bands.  They  are,  however, 
seldom  if  ever  required.  Nasal  pins  or  intra-nasal  supports  are  less 
conspicuous  and  if  judiciously  adjusted  answer  the  purpose  well  in 
nearly  all  cases. 

When  there  is  a  tendency  for  the  broken  bones,  forming  the  bridge 
of  the  nose,  to  fall  inward,  because  of  comminution  or  unusual  separa- 
tion of  their  attachments,  support  may  be  given  them  by  the  ''tie 
beam"  method.  This  is  done  by  thrusting  a  steel  pin  transversely 
through  the  bridge  of  the  nose  below  the  fractured  nasal  bones,  through 
the  nasal  processes  of  the  maxillary  bones,  or  between  some  of  the 
comminuted  fragments.  If  this  support  is  not  sufficient,  the  nasal 
structures  may  be  pinched  together  by  the  surgeon's  fingers,  and  a 
flat  shot  clamped  on  each  end  of  the  pin.  Between  the  skin  and  the 
shot  a  small  disk  of  sterilized  rubber  may  be  placed  to  prevent  ulcera- 
tion from  pressure  on  the  skin.  The  lateral  pressure  and  the  tie-beam 
need  not  be  continued  longer  than  two  or  three  days. 

Instead  of  the  pin  a  rubber  thread  may  be  carried  across  under  the 
replaced  bones;  and  shot,  protected  by  rubber  disks,  be  clamped  upon 
its  ends  to  make  sufficient  lateral  pressure.  Then  the  swelling  of  the 
soft  parts  stretches  the  rubber  band  and  injurious  pressure  by  the  shot 
on  the  skin  is  avoided. 

The  mucous  membrane  lining  a  broken  nose  seldom  needs  attention 
except  that  the  nasal  cavities  should  be  more  or  less  frequently 
flushed  out  or  cleansed  with  sterile  normal  salt  solution  or  some 
mild  antiseptic  spray  or  wash,  such  as  the  compound  solution  of 
sodium  borate. 

Old  unreduced  fractures  and  dislocations  require  osteotomy  or 
refracture  and  readjustment.  Much  can  be  done  by  dividing  cartilage 
and  bone  from  within  the  nose.  The  operator  punctures  the  mucous 
membrane  in  the  necessary  places  and  by  thrusting  small  saws  or 
chisels  under  it  reaches  the  bone  or  cartilage  to  be  divided.  The 
overlapping  soft  parts  may  be  detached  from  the  bones  and  cartilages 
by  the  free  use  of  a  tenotome.  When  necessary,  small  external  in- 
cisions may  be  made  to  admit  a  small  saw  or  chisel  or  a  tenotome. 


188 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


These  often  need  no  subsequent  suture  to  close  them.  To  uncover 
more  extensive  areas  incisions  and  flaps  may  be  made  with  small 
sharp  knives.  After  the  bones  have  been  divided  and  the  readjust- 
ment has  been  completed,  fine  sutures  of  linen  or  silk  restore  the 
cutaneous  surface.  The  scars  soon  disappear,  especially  if  the  cut  in 
the  skin  has  been  made  obliquely  to  the  surface. 

Sometimes  saddle  noses  due  to  fractures  can  best  be  corrected 
by  subcutaneous  paraffin  injections.  Instead  of  using  hot  paraffin, 
cold  or  more  or  less  solid  paraffin  may  be  used,  as  in  other  cases  of 
sunken  bridge,  if  the  dangers  of  embolism  are  feared.  This  material 
is  best  injected  with  a  syringe,  having  a  piston  driven  by  a  screw 
attachment,  and  needles  of  large  calibre. 

H.  P.  Mosher  has  given  a  good  description  of  the  mechanism  of 
the  deformities  due  to  fractures  and  luxations  of  the  nasal  bones  and 


Fig.  178. — Diagram  showing  relation  of  nasal  bones  to  nasal  processes  of  superior  maxiUEe.  a, 
maxillary  process;  h,  nasal  bones.  1,  normal;  2,  fracture-dislocation  of  nasal  bones  toward  right, 
over-riding  maxillary  process;  3,  depression  of  nasal  bones  beneath  maxillary  processes.  {H.  P. 
Mosher.) 

cartilages.     He   has   made   valuable   suggestions   for   unlocking   the 
impacted  bones  and  reducing  the  displaced  or  luxated  structures. 

In  old  uncomplicated  lateral  deviation  of  the  bony  bridge  of  the 
nose  Mosher  makes  a  small  incision  in  the  skin  at  the  outer  border  of 
the  lower  part  of  the  nasal  bone.  With  a  chisel  about  1/8  of  an  inch 
wide  he  cuts  this  bone  from  the  ascending  process  of  the  maxilla.  By 
slipping  up  the  skin  this  can  be  done  through  a  very  small  incision.  He 
then  turns  the  chisel  at  right  angles  and  cuts  the  nasal  bone  loose 
from  the  frontal.  This  detachment  is  made  on  both  sides  of  the  nose 
and  must  be  complete  so  that  the  bony  nasal  bridge  is  freely 
movable.  It  is  returned  to  its  normal  position  in  the  median  line  and 
held  there  by  some  form  of  external  spHnt.     Modelling  compound 


DEFORMITIES  OF  THE  NOSE 


189 


or  superimposed  layers  of  adhesive  plaster  will  usually  be  sufficient. 
When  the  lateral  deformity  involves  the  cartilaginous  as  well  as 
the  bony  bridge,  the  septal  cartilage  is  usually  bent  and  therefore 
occludes  the  naris  on  one  side.  Mosher  says  that  the  perpendicular 
rectangular  deviation  makes  a  knuckle  in  the  quadrangular  cartilage. 
This  prominence  should  be  dissected  out  submucously.  He  stops 
removing  the  cartilage  a  quarter  of  an  inch  from  the  top  of  the  carti- 
laginous bridge.  If  the  upper  lateral  cartilage  is  displaced,  it  is 
removed  by  dissection  within  the  nose.  When  these  intra-nasal  pro- 
cedures are  completed,  the  nasal  bones  are  chiseled  loose  as  described 


Nasal  bone  overriding 
the  nasal  process  of 
the  superior  maxilla 


Depressed 
nasal  bone. 


FiG.  179. — Method  of  reducing  with  thumb  and  elevator  fracture-dislocation  of  nasal  bones. 
The  right  nasal  bone  overrides  maxillary  process,  the  left  is  depressed  and  caught  under  its  fellow 
and  under  the  left  maxilla.     (H.  P.  Mosher.) 


above  and  returned  to  their  normal  median  situation.  There  may 
remain  a  protuberance,  clue  to  the  prominence  of  the  nasal  process  of 
a  maxilla,  from  which  a  nasal  bone  has  been  chiseled  loose.  This  is 
cut  off  with  a  chisel,  entered  through  the  cut  made  to  get  access  for 
the  nasal  osteotomy,  and  then  is  shoved  down  toward  the  interior 
of  the  nose. 

Sometimes  there  remains  lateral  deformity  at  the  point  where 
the  bony  bridge  and  the  cartilaginous  bridge  join.  The  sldn  should 
be  cut  at  this  point  and  a  chisel  used  to  separate  the  quadrangular 
septal  cartilage  from  the  under  surface  of  the  tip  of  the  nasal  bone. 
If  this  maneuvre  is  not  sufficient  to  allow  the  operator  to  straighten 
the  nose,  a  half  inch  incision  should  be  made  downward  and  backward 
into  the  perpendicular  plate  of  the  ethmoid.  Then  a  straight  nose 
may  usually  be  obtained  by  modeling.  Proper  retentive  appliances 
should  be  employed  for  two  or  three  days. 


190 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


If  the  external  incisions  described  for  replacing  nasal  bones  after 
mal-union  following  fracture,  are  undesirable,  the  nasal  bones  may  be 
loosened  from  their  attachments  to  the  maxillse  and  frontal  bone  by 
working  within  the  nose.  The  mucosa  is  incised  at  the  lower  border 
of  each  nasal  bone  and  the  muco-periosteum  detached  by  elevators 
introduced  through  the  respective  naris.  The  skin  and  periosteum  is 
similarly  detached  from  the  upper  surface  of  each  bone  by  similar 
intra-nasal  manipulation.  The  nasal  bones  are  then  in  turn  grasped 
by  strong  flat  forceps,  thrust  through  the  nostril,  and  are  wrenched 
from  their  neighbors.  They  are  then  moulded  with  the  fingers  into 
the  proper  site  to  render  the  nose  straight  and  are  maintained  there 
by  splints  or  similar  devices.     This  subperiosteal  method  is  more 


Incision  through  the  root  of  nasal  bone. 


Fig.   180. — Diagram  to  illustrate  correction  of  lateral  deformity  of  the  nose  by  direct  chiseling 
of  bone.     Dark  line  shows  skin  wound;  dotted  lines  bone  incisions  with  chisel.     {H.  P.  Mosher.) 

troublesome  than  that  by  cutaneous  incision.  It  is  probably  not  as 
good.  The  external  route  is  more  surgical;  and  as  the  scars  made  by  its 
adoption  are  inconspicuous  after  a  few  months,  it  is  usually  the  prefer- 
able procedure. 

Deformities  from  Tumors.     Operations  for  Obtaining  Access  to  the 

Interior  of  the  Nose. 

The  nose  may  be  deformed  by  the  occurrence  of  tumors,  benign 
or  malignant,  upon  its  surface,  and  also  by  similar  growths  located 
within  its  chambers  and  secondarily  displacing  its  walls. 

In  the  first  group  are  the  protuberances  caused  by  such  diseases  as 
acne  rosacea,  rhino-sclerema,  sebaceous  cysts,  warts,  epithelioma  and 


DEFORMITIES  OF  THE  NOSE 


191 


syphilitic  gummas.  In  the  second  are  found  polypus,  fibromas, 
sarcomas,  and  endotheliomas.  The  peculiar  distortion  of  the  nose 
called  frog-face  is  due  to  a  dilation  of  the  walls  enclosing  the  nasal 
cavities,  by  tumors  situated  within  them. 

These  deforming  influences  must  be  treated  medicinally  or  surgi- 
cally according  to  their  character  and  degree.  Their  relation  to  the 
present  discussion  depends  upon  their  ability  to  cause  disfigurement. 
Early  removal  or  cure  is  therefore  important.  The  cases  requiring 
operation  should  be  studied  with  the  idea  of  adopting  the  least  muti- 
lating method,  or  that  which  will  at  most  leave  a  defect  readily  reme- 
died by  a  secondary  plastic  reconstruction. 


Fig.   181. — Rouge's  method  of  gaining  access  to  the  internal  nose  by  an  incision  within  the 
mouth  between  the  upper  Up  and  upper  alveolus,  which  permits  elevation  of  lip  and  nose. 


Gangrene  from  injury,  burning,  frostbite  or  ergo  tic  poisoning  is  a 
cause  of  loss  of  tissue,  which  may  be  as  deforming  from  cicatricial 
contraction  as  losses  from  accidental  wounds.  Syphilis,  tuberculosis 
and  some  other  infections  may  lead  to  destruction,  by  ulceration  or 
necrosis,  of  both  hard  and  soft  nasal  tissues.  Distortions  from  such 
conditions  or  from  cicatricial  contraction,  following  their  relief, 
require  at  times  the  highest  skill  for  reconstructive  success. 

Many  forms  of  operation  will  be  discussed  in  the  chapter  on  rhino- 


192 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


plasty,  which  may  serve  as  a  basis  for  surgical  relief  or  as  suggestions 
to  inspire  operators  to  ingenuity  in  devising  other  procedures. 

The  superficial  cutaneous  disfigurements  of  the  face  and  nose  have 
been  discussed  in  another  chapter  of  this  book.  Syphilitic  and  tuber- 
cular conditions  demand  active  medicinal  and  hygienic  treatment. 
The  diagnosis  of  lupus,  a  tuberculous  lesion,  from  syphilis  and  eptihe- 
lioma  may  be  difficult;  but  it  is  important  that  a  correct  decision  should 
if  possible,  be  made  early.  The  delay  occasioned  by  failure  to  recog- 
nize the  causation  of  the  deforming  growth  or  ulceration  may  permit 
irreparable  loss  of  tissue. 


Fig.   182. — Boeckel's  incision  for  temporary  osteoplastic  displacement  of  nose. 

Tumors  involving  the  nasal  cavities  or  the  accessory  sinuses  of 
the  nose  deform  the  face,  as  do  growths  of  the  maxillae  and  mandible- 
Many  of  them  require  temporary  plastic  or  osteoplastic  resection  of 
the  structures  about  the  nose  and  mouth,  so  as  to  give  access  for 
operative  treatment.  Others  necessitate  wide  removal  of  soft  jDarts 
or  bone,  in  order  to  eradicate  the  neoplasm;  and  as  a  result  extensive 
plastic  reparation  must  be  undertaken,  either  at  once  or  as  a  second- 
ary procedure. 

Incision  or  resection  of  the  palate,  both  hard  and  soft  if  necessary, 
allows  the  operator  to  reach  the  nasal  cavities  and  nasopharynx  from 
the  mouth.     The  displacement  of  bone  may  be  temporary  or  per- 


DEFORMITIES  OF  THE  NOSE 


193 


manent.  The  alae  and  columella  may  be  separated  from  the  rest  of 
the  face  by  incisions  in  the  furrows  around  and  under  them  and  the 
nose  lifted  up.  Careful  suturing  after  replacement  leaves  a  scar 
which  is  scarcely  noticeable. 

By  carrying  a  knife  transversely  in  the  groove  between  the  gum 
and  the  everted  upper  lip,  the  nose  and  the  cheeks  may  be  pulled 
upward  so  as  to  expose  fully  the  anterior  openings  into  the  chambers 
of  the  nose. 

More  extensive  temporary  displacements  of  the  nose  may  be  made 
by  dividing  its  bony  attachments  to  the  face.     The  external  nose 


Fig    183. — Ollier's  incision  for  temporary  osteoplastic  displacement  of  nose. 

may  be  thus  displaced  downward,  laterally,  or  upward.  By  dividing 
in  addition  the  upper  lip  at  or  near  the  middle  line,  after  the  nose  has 
been  displaced  upward,  much  of  the  upper  jaw  can  be  reached  for 
operative  treatment.  If  the  nose  is  temporarily  resected  and  turned 
up,  the  upper  lip  divided  and  an  incision  carried  from  the  nasal  region 
outward  beneath  the  lower  eyelid,  the  whole  of  the  upper  jawbone 
and  the  malar  bone  are  revealed  to  the  surgeon's  eye  or  knife. 

After  the  bones  of  the  face  have  been  uncovered  by  any  one  of 
the  various  incisions  described,  the  operator  must  make  such  sections 
of  the  bone  as  will  best  subserve  his  purpose. 

The  mandible  is  made  accessible  by  dividing  the  lower  lip  from 


194 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


mouth  to  a  selected  point  under  and  back  of  the  chin,  and  carrying 
an  incision  from  this  cut  outward  toward  one  or  both  ears,  hugging 
the  lower  border  of  the  bone.  An  even  better  exposure  may  be  made 
by  sawing  through  the  bone  near  the  median  line.  The  cut  should  be 
made  in  a  sigmoid  curve. 

As  has  been  said  previously  much  operative  work  can  be   done 
within  the  mouth,  and  also  indeed  within  the  nose,  without  external 


Fig.  184. — Lawrence's  incision  for  temporary  osteoplastic  displacement  of  nose. 

incisions,  provided  that  the  operator  has  the  instruments  of  the  oral 
surgeon  or  dentist  and  has  practical  skill  in  their  use. 

The  lateral  aspect  of  the  bony  face  may  be  exposed  by  a  tempo- 
rary division  of  the  zygoma  and  pulling  the  fragments  apart  by 
strong  retractors.  The  holes  for  subsequent  suture  of  the  bone  with 
catgut  or  wire  should  be  bored  before  the  saw  is  used  to  divide  it. 
In  a  somewhat  similar  manner  the  malar  bone  may  be  displaced 
temporarily  outward  as  in  the  operation  of  Kocher  for  resecting  the 
infra-orbital  nerve. 


CHAPTER  XIV. 
RHINOPLASTY. 

The  surgery  of  the  external  nose  deserves  more  attention  than  is 
usually  given  it.  The  cosmetic  value  of  the  organ  is  very  great  and 
the  possibilities  of  relief  in  cases  of  deformity  are  apparently  not 
appreciated  to  their  full  extent  by  the  medical  profession  or  the 
public.  The  satisfaction  often  exhibited  by  patients,  after  experien- 
cing the  facial  improvement  obtained  by  slight  operations,  and  the 
endurance  with  which  others  will  submit  to  a  series  of  complicated 
and  painful  procedures  are  evidence  of  the 
importance  of  this  kind  of  surgical  endeavor. 
Very  much  can  be  gained  by  operative  recon- 
struction without  resort  to  bizarre  methods. 

Punitive  losses  of  the  external  nose  were 
common  in  the  ancient  and  medieval  worlds, 
and  are  still  frequent  in  oriental  countries. 
Such  traumatisms  concern,  as  a  rule,  only 
the  integument  and  cartilages  below  the 
nasal  bones.  Hence  they  are  repaired  by 
plastic  operations  more  easily  and  satisfac- 
torily than  deformities  resulting  from  syphilis, 
gunshot  injuries,  or  extensive  operations 
for  tumors.  These  causes  of  disfigurement 
often  involve  the  bony  and  cartilaginous 
structures  within  the  nasal  chambers,  as  well  as  the  projecting  external 
nose.  When  the  nasal  bones  constituting  the  bridge  of  the  nose  have 
been  lost  or  the  supports  of  the  external  cartilaginous  nose  have  been 
destroyed  by  syphilis,  the  reconstructive  problem  is  much  more 
difficult  than  when  the  cartilaginous  nose  has  been  merely  sliced  off 
by  the  sword  of  an  antagonist  or  the  knife  of  an  avenger. 

The  inherent  trouble  in  all  extensive  nasal  reconstructions  is  the 
obtaining  of  sufficient  permanent  projection  from  the  surface  of  the 
face.  It  is  an  easy  task  to  put  a  flat  mass  of  skin  and  fascia  in  the 
region  of  the  nose.  It  may  not  be  very  difficult  to  even  give  it  at  the 
time  the  prominence  and  general  shape  of  a  nasal  organ.  To  main- 
tain permanently  the  shape  and  prominence  of  the  new  nose,  despite 

195 


Fig.  185. — Specific  necrosis 
of  nose  in  infancy.  (Author's 
patient.) 


196 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


the  contracting  power  of  scar-tissue,  is  the  surgeon's  real  difficulty. 
To  obtain  nares  which  will  remain  patent  and  a  columella  which  will 
resist  deformity  from  postoperative  contraction  is  often  practically 
impossible.  When  the  ulcerative  process  of  syphilis,  tuberculosis, 
or  malignant  disease,  or  when  gangrene  from  burns,  frost-bite,  or 
caustics  has  destroyed  the  cutaneous  surface  around  the  nose,  it  be- 
comes necessary  for  the  surgeon  to  transfer,  or  transplant,  healthy 
tissues  from  other  regions  to  replace  the  scar  tissue. 

It  is  gratifying  to  find  that  inherited  syphilis  of  the  nose  seems 
to  be  less  apt  to  involve  the  skin  than  the  acquired  disease.  Unfor- 
tunately both  forms  of  this  loathsome  affection  destroy  the  bones  and 
cartilages  upon  which  the  contour  of  the  external  nose  depends. 
Much  nasal  deformity  and  mental  suffering  may  be  avoided  by  the 


Fig.  186. — Dieffenbach's  method  ot  modeling  brachial  flap  before  attaching  it  to  nasal  region. 


early  recognition  of  syphilitic  lesions  of  the  nose  and  the  prompt 
institution  of  efficient  specific  treatment.  I  was  never  convinced  of 
the  propriety  of  waiting  for  the  development  of  secondary  lesions 
before  treating  suspicious  sores  with  mercury;  nor  can  I  understand 
the  folly  of  treating  tertiary  lesions  with  small  and  therefore,  inefficient 
doses  of  mercury  and  potassium  iodide.  Our  knowledge  of  the  micro- 
organism, which  is  now  the  recognized  cause  of  syphilis,  and  of  the 
reactions,  which  aid  in  diagnosticating  its  presence  in  the  human 
body,  has  made  it  easier  to  reach  a  conclusion  as  to  the  character  of 
ulcerating  lesions  of  the  face  than  was  possible  a  few  years  ago.  The 
destruction  of  the  nasal  structures,  from  insufficiently  treated  syphilis, 
should  as  a  result  of  this  progress  in  medicine  become  gradually  more 
infrequent. 


RHINOPLASTY 


197 


Portions  of  nose  accidentally  cut  off  should  be  immediately  re- 
placed and  sutured  after  aseptic  cleansing.  Their  permanent  union 
may  sometimes  be  obtained  if  the  parts  are  kept  warm. 

Rhinoplastic  operations  are  important  because  of  the  cosmetic 
value  of  a  comely  nose.  The  psychic  effect  of  a  knowledge  of  marked 
facial  disfigurement,  especially  if  due  to  syphilis,  is  sufficient  to  affect 
the  patient  deleteriously  in  both  disposition  and  earning  capacity. 
Suits  to  recover  damages  for  nasal  disfigurement  indicate  that  a 
distinct  commercial  value  is  attached  to  comeliness  of  countenance. 

Total  rhinoplasty  should  mean  reconstruction  of  the  whole  nose 
below  the  frontonasal  suture,  but  the  term  is  often  used  when  the 
loss  of  the  organ  begins  below  the  nasal  bones.  Pedunculated  flaps 
for  the  reconstruction  may  be  taken  from  the  patient's  arm,  forehead, 


Fig.  187. — Diagram  of  Keegan's  operation  for  rhinoplasty.  The  flaps  C  A  B  D  and  G  E  F  H 
are  dissected  from  surface  of  nasal  bones  and  bent  downward  as  if  on  hinges  at  CD  and  G  H.  The 
second  diagram  shows  Keegan's  method  of  cutting  the  frontal  flap  and  applying  the  sutures  to  the 
frontal  wound.      {From  Keegan's  Rhinoplastic  Operations.) 

or  cheeks.  Brachial  flaps  require  the  arm  and  the  head  to  be  held  in 
apposition  by  gypsum  bandages  or  other  retentive  apparatus  for 
about  two  weeks.  A  flap  cut  on  the  upper  arm  or  forearm  may  be 
permitted  with  advantage  to  contract  and  thicken  by  cicatricial 
changes  or  be  moulded  somewhat  into  shape,  before  the  arm  and 
head  are  approximated  and  the  flap  sutured  in  the  nasal  region. 
Lexer^  has  carved  a  nose  from  the  condyles  of  an  amputated  femur, 
bored  holes  for  nostrils,  planted  the  bony  mass  under  the  skin  of  the 
forearm,  and  subsequently  transplanted  it  upon  the  face. 

The  frontal  method  has  the  advantages  that  it  requires  no  re- 
straint in  the  patient's  posture,  and  that  strips  of  periosteum  or  bone 
cut  with  the  flap  from  the  forehead  may  be  embedded  in  the  new 

^  "Verhandl.  der  deutsch.  Gesell.  f.  Chirurgie,"  1908,  ii. 


198 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


nose  with  comparative  ease  and  considerable  advantage.  There  are 
numerous  modifications  of  these  osteoplastic  methods.  The  scarring 
of  the  frontal  region  is  a  disadvantage,  but  this  may  be  minimized  by 
aseptic  methods  and  skin  grafting. 

In  partial  rhinoplasty  pedunculated  flaps  are  often  taken  from  the 
cheeks.  If  cut  in  the  direction  of  the  nasolabial  furrows,  such  flaps, 
even  when  large,  leave  comparatively  little  objectionable  scarring. 
The  incidental  diminution  of  the  prominence  of  the  cheeks  increases 
the  relative  projection  of  the  plastic  reconstruction  of  the  nose,  and  is, 
therefore,  a  cosmetic  benefit. 

Superimposed  flaps  may  be  necessary  in  nasal  reparations,  in 
order  to  give  to  the  structures  sufficient  thickness  and  rigidity  to 
retain  nasal  prominence. 

Free  flaps  of  integument  from  the  inner 
surface  of  the  thigh  or  arm  may  be  utilized,  if 
careful  asepsis  is  obtained  and  maintained 
during  the  transplantation  and  after-dressing. 
Such  non-pedunculated  flaps  cannot  be  used 
with  much  hope  of  success,  when  the  raw  sur- 
faces or  edges  are  subjected  to  direct  com- 
munication with  the  nasal  chambers.  Infec- 
tion is  then  too  probable. 

Portions    of     cartilage    taken    from    the 
f  ^Pim^^E      patient's  ribs  or  ear,  pieces  of  bone  from  the 

forehead,  tibia,  ulna,  ilium,  a  finger  or  toe,  or 
strips  of  bone  or  periosteum  from  a  rabbit's 
femur,  may  be  implanted  in  the  soft  tissues 
used  to  repair  the  nose.  These,  if  aseptic, 
become  incorporated,  and  may  give  permanent 
rigidity  to  the  newly  made  nose.  Such  organic 
implantations  are  preferable  to  inorganic  implantations  or  supports 
of  celluloid  or  metal. 

The  method  of  Keegan,  whose  service  in  India  gave  unusual  op- 
portunity for  practical  experience  in  dealing  with  mutilations  of  the 
nose,  is  probably  the  best  rhinoplastic  operation,  when  the  nasal  bones 
and  the  skin  covering  them  have  been  preserved. 

The  operator  first  dissects,  from  above  downward,  two  flaps  from 
the  surface  of  the  nasal  bones  and  turns  these  down  as  on  a  hinge, 
at  the  lower  border  of  the  bony  nasal  bridge.  This  gives  a  cutane- 
ous surface  toward  the  open  nasal  chambers  and  a  raw  surface  from 
the  root  of  the  nose  to  its  proposed  tip. 

An  oblique  frontal  flap  is  then  cut  with  its  pedicle  near  the  inner 


Fig.  188. — Patient  operated 
upon  by  Major  Henry  Smith  by 
his  modification  of  Keegan's 
method.  {Courtesy  of  Dr.  D. 
F.  Keegan.) 


RHINOPLASTY 


199 


canthus  of  one  eye,  so  that  it  may  be  nourished  by  the  angular  artery. 
The  alae  and  columella  are  provided  for  in  forming  this  flap. 

The  size  and  exact  shape  of  this  frontal  flap  have  been  previously 
determined  by  cutting  a  piece  of  a  flexible  leaf  to  meet  the  special 
requirements  of  the  deformity.     This  is  copied  in  paper  and  the  paper 


Fig.   189. 


Fig.   190. 


Fig.  189. — Charles  Nelaton's  method  of  giving  rigidity  to  the  frontal  flap  by  previous  implanta" 
tion  of  a  piece  of  the  eighth  costal  cartilage  under  the  periosteum  of  the  forehead  in  total  loss  of 
the  external  nose. 

Fig.  190.^E version  and  modelUng  of  the  frontal  flap  in  Nelaton's  method. 


Fig.  191. 


-The  new  nose,  formed  from  a  frontal  flap  and  implanted  cartilage,  sutured  to  the 
cheeks  and  lip.      (Nelaton  and  Ombredanne.) 


fastened  to  the  skin  of  the  forehead  before  the  knife  which  marks  out 
the  flaps  is  used.  The  flap  is  then  raised,  its  pedicle  twisted,  and 
sutures  are  used  to  fasten  it  over  the  bared  nasal  bones  and  the  turned- 
down  flaps  covering  the  opening  into  the  nose.  A  pit  is  made  above 
the  middle  of  the  upper  lip  to  receive  the  projection  forming  the 
columella,  and  the  wounds  on  the  side  of  the  nose  are  deepened  and 


200 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


lengthened  to  receive  the  edge  of  the  flap  from  the  forehead.  The 
frontal  wound  is  closed  by  sutures  and  with  grafts  made  from  any 
excess  of  tissue  removed  from  the  nasal  or  frontal  flaps.  Drain  tubes 
are  kept  in  the  nostrils  for  a  few  days  to  maintain  patency  and  the 
pedicle  is  divided  in  ten  or  fourteen  days. 

Instead  of  trimming  away  the  median  margins  of  the  everted 
nasal  flaps,  which  are  voluminous,  Henry  Smith  splits  the  remains 
of  the  nasal  septum,  inverts  these  median  edges  into  the  nasal  cavity, 
and  stitches  them  to  the  respective  sides  of  the  split  septum.  He 
thus  creates  a  new  septum  and  columella,  and  lines  more  of  the  interior 
of  the  new  nose  with  skin. 

If  the  septum  and  columella  thus  made  are  not  sufficiently  rigid. 


Fig.  192. — Before  operation.  Fig.   193. — Several  years  after  operation. 

Rhinoplastic  restoration  of  the  alse  and  lobule  of  the  nose  by  a  frontal  flap. 
{Dr.  Wm.  G.  Porter's  case.) 


a  strip  of  cartilage,  cut  from  the  end  of  one  of  the  patient's  costal 
cartilages,  might  be  subsequently  thrust  into  the  new  partition  to 
give  it  rigidity. 

A  valuable  method  of  total  rhinoplasty  is  that  of  Charles  Nelaton. 
He  excises  nearly  the  entire  length  of  the  cartilage  of  the  eighth  left 
rib  and  trims  its  end  for  about  2.5  cm.  down  to  a  thickness  of  3  mm. 
This  strip  of  cartilage  he  notches  where  it  is  expected  to  make  the 
point  of  the  nose.  Then  he  thrusts  it  into  a  horizontal  tunnel  between 
the  bone  and  periosteum  of  the  forehead.  In  two  months  the  car- 
tilage becomes  vitally  connected  with  the  surrounding  tissues.  The 
cicatricial  borders  of  the  nasal  stump  are  then  pared  loose,  making 
three  flaps.  These  are  turned  downward  and  inward  and  are  sutured 
together  so  as  to  close  more  or  less  completely  the  upper  part  of  the 


RHINOPLASTY  20l 

gap  left  by  the  loss  of  the  external  nose.  The  raw  surface  of  these 
flaps  presents  forward. 

An  irregularly  quadrilateral  flap  is  then  cut  from  the  forehead, 
with  its  pedicle  at  the  inner  border  of  the  right  eyebrow,  containing 
the  transplanted  costal  cartilage  in  its  middle  line.  This  flap  is  raised 
from  the  bone,  carrying  with  it  the  entire  periosteum  and  the  im- 
planted costal  cartilage.  It  is  twisted  downward  and  sutured  on  top 
of  the  nasal  flaps  just  mentioned.  By  appropriate  modelling  with 
stitches  an  acceptable  nose,  with  alse,  columella,  and  nostrils,  is  formed. 

The  frontal  bone  may  lose  a  thin  layer  of  its  surface  by  necrosis 
because  its  periosteum  has  been  removed,  but  when  granulation  has 
occurred  Thiersch  skin  grafts  are  applied,  and  the  final  scarring  is 
said  to  be  not  very  deforming. 

In  brachial  rhinoplasty  the  flap  for  the  new  nose  may  be  cut  from 
the  upper  arm  or  the  forearm;  or  a  pedunculated  flap  from  the  chest 
or  abdomen  may  be  grafted  upon  the  arm  and  subsequently  applied 
to  the  nasal  region,  just  as  if  it  had  originally  been  formed  from 
brachial  tissues.  The  retentive  apparatus  to  hold  the  arm  close  to 
the  face  may  be  made  from  bandages  and  gypsum  or  from  leather  and 
webbing.  The  patient  may  be  fitted  with  such  appliances  and  wear 
them  for  a  time  prior  to  operation,  in  order  to  become  inured  to  the 
discomfort  due  to  their  use.  The  brachial  method  is  of  more  value 
probably  when  partial  rhinoplasty  is  to  be  done,  because  it  scarcely 
ever  can  give  sufficient  rigidity  to  form  an  acceptable  organ  in  total 
rhinoplasty. 

Schimmelbuscli  has  devised  a  method  in  which  he  uses  a  large 
osteoplastic  flap  from  the  forehead  and  slides  large  areas  of  the  scalp 
from  the  temporal  regions  to  cover  the  denuded  space.  The  bony 
flap  is  covered  with  Thiersch  grafts  anci  then  reversed. 

Some  operators  have  employed  both  frontal  and  brachial  flaps, 
superimposing  one  upon  the  other. 

For  the  various  deformities  requiring  partial  rhinoplasties  there 
are  almost  innumerable  operative  devices. 

In  subtotal  loss  of  the  organ,  Charles  Nelaton  has  sawed  a  long 
A-shape  flap  from  the  forehead  and  nasal  margins,  containing  a  plate 
of  bone  from  the  frontal  bone  and  edges  of  the  nasal  and  superior 
maxillary  bones.  This  osteoplastic  A-shape  flap  is  slipped  downward 
and  bent  into  shape  to  make  a  nose  in  the  nasal  region. 

Bardenheuer  has  devised  a  support  for  the  anterior  part  of  a  new 
nose  by  incising  the  osteocartilaginous  septum,  if  any  remains,  and 
turning  forward  a  triangular  flap,  which  projects  beyond  the  plane 
of  the  face.     On  this  support  cellulocutaneous  flaps  are  placed. 


202 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Fig.  194. 


Fig.  195. 


Fig.  196. 
Figs.  191,  195  and  196. — Schimmelbusch's  total  rhinoplasty  by  means  of  an  osteoplastic  frontal 
flap,  followed  by  lateral  sliding  of  the  skin  of  the  temporal  regions  toward  the  middle  line.  Tri- 
angular areas  of  skin  are  removed  at  1  in  Fig.  194  to  permit  apposition  of  the  displaced  temporal 
integuments.  The  new  columella  is  made  from  the  remains  of  the  alae  as  shown  in  Figs.  194  and 
195.  In  Fig.  196  the  reconstruction  is  shown  as  it  appears  after  the  sutures  have  been  applied. 
{Fowler's  Surgery.) 


RHINOPLASTY 


203 


The  method  described  by  Cheyne  and  Burghard  may  be  found 
valuable  in  some  cases  of  saddle  nose. 

Noses  in  which  depression  of  the  bridge  is  great  and  especially 
those  in  which  the  skin  is  bound  down  by  old  inflammatory  adhesions 
demand  radical  operative  procedures.     The  sunken  noses  of  syphilis, 


Fig.  197. 


Fig.   198. 


Fig.   199.  Fig.  200. 

Figs.   197,  198,  199  and  200. — Charles  Nelaton's  method  of  osteoplastic  rhinoplasty  in  partial  loss 
of  the  external  nose.      (A^elaton  and  Ombredanne.) 


with  adhesions  between  the  skin  and  the  remains  of  the  destroj'ed 
internal  structures  of  the  nose,  belong  to  this  class.  These  distress- 
ingly ugly  noses  often  have  a  sharply  defined  transverse  groove  across 
the  middle  of  the  sunken  area  and  the  adherent  integument  is  prac- 
tically indistensible  from  cicatricial  fibrous  change.  The  term  sunken 
nose  is  more  applicable  than  saddle  nose.     In  some  of  these  cases  the 


204 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


skin  of  the  nose  should  be  detached  from  the  bones  by  an  inverted 
U-incision,  and  a  frontal  flap  turned  down  and  tucked  under  it.  A 
piece  of  cartilage  or  bone  may  be  incorporated  in  or  between  these 


Fig.  201. 


Fig.  202. 


Figs.  201  and  202. — Bardenheuer'a  method  of  supporting  nose  made  of  soft  tissues  with  flap  of 

septum  turned  forward. 


Fig.  203. — Restoration  of  the  bridge  of  the  nose  by  insertion  of  a  strip  of  integument,  perios- 
teum and  bone,  from  the  middle  frontal  region,  under  the  dorsal  structures  of  the  nose.  A,  Shows 
incisions;  B,  shows  dorsal  structures  opened  like  window  shutters  and  the  frontal  osteo-periosteal 
strip  bent  downward;  C,  shows  the  new  bridge  in  position;  Z),  shows  the  wounds  closed.  (Cheyne 
and  Burghard.) 

superimposed  flaps.  Occasionally  the  tissues  may  be  satisfactorily 
raised  by  undermining  the  skin  with  a  tenotome  and  injecting  semi- 
solid paraffin. 

The  worst  forms  of  syphilitic  sunken  nose  require  still  more  ex- 


RHINOPLASTY 


205 


tensive  operative  reconstruction.  The  first  step  should  be  a  deep 
cut  across  the  sunken  region  in  the  transverse  groove.  This  incision 
opens  the  nasal  cavity  and  permits  the  lobule  and  alee  to  be  displaced 
downward  and  forward  into  the  normal  position.  This  maneuver 
restores  the  prominence  of  the  tip,  or  lobule,  and  makes  the  nostrils 
again  lie  in  the  horizontal  plane.     The  next  step  is  to  fill  the  gaping 


Fig.  204.  Fig.  205.  Fig.  206. 

Figs.  204,  205  and  206. — Diagram  of  method  of  correcting  a  sunken  sj'philitic  nose  of 
moderate  severity.     {Author's  case.) 

opening  between  the  lower  margin  of  the  bony  bridge  above  and  the 
replaced  lobule  and  alse  below.  The  tissues  used  to  close  this  large 
orifice  must  be  permanently  thick  and  rigid.  Flaps  ma}^  be  taken  from 
the  forehead  or  cheeks,  or  preferably  from  both. 

I  devised  some  years  ago  a  method  which  answers  well.     The 
first  stage  consists  in  cutting  a  flap  from  each  cheek  near  the  naso- 


FiG.  207. — Lateral  view  of  patient  operated  on  by  method  shown  in  Fig.  204  after  some  additional 

minor  operations. 

labial  furrow.  These  are  turned  upward  and  inward  to  meet  the 
median  line  and  thus  cover  in  the  opening.  The  skin  surface  is 
toward  the  nasal  chamber.  After  these  flaps  have  been  united  and 
cicatrized,  the  irregularities  at  their  base  are  corrected  by  incisions 
and  sutures.  The  next  major  procedure  is  to  make  an  inverted  V 
incision,  from  the  middle  of  the  forehead,  the  legs  of  which  run  down- 
ward and  outward  to  points  on  the  cheeks  below  the  eyes.     Just  above 


206 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


the  granulating  surface  on  the  former  flaps,  which  closed  the  opening, 
a  similar  inverted  V-shape  cut  is  made.  The  apices  of  these  two  cuts 
are  joined  by  a  vertical  incision  in  the  middle  line.  This  series  of 
incisions  marks  out  two  rhomboidal  flaps  with  their  pedicles  on  the 
cheeks  close  to  the  sides  of  the  nose.  These  flaps  are  then  raised  from 
the  frontal  and  nasal  bones  and  rotated  downward  over  the  cicatri- 
cial or  granulating  surface  of  the  reversed  cheek  flaps,  previously 


Fig.  208. 


Fig.  209. 


Fig.  210.  Fig.  211. 

Figs.  208,  209,  210  and  211. — Roberts's  method  of  operating  upon  the  sunken  nose  of  syphilis  by- 
superimposed  flaps  from  cheek  and  nasofrontal  regions. 

used  to  close  the  opening  into  the  nasal  chambers.  The  upper  angle 
of  the  right  flap  is  sutured  to  the  base  of  the  left  ala,  and  that  of  the 
left  flap  is  turned  so  as  to  reach  across  to  a  point  near  the  inner  can- 
thus  of  the  right  eye.  Sutures  are  employed  to  maintain  the  new 
relations  of  the  frontonasal  flaps,  which  have  been  laid  upon  the  over- 
turned cheek  flaps;  and  the  wound  on  the  forehead  is  easily  closed  in 
\  a  vertical  direction.  The  scars  are  inconspicuous,  and  much  rigidity 
is  given  to  the  tissue  interpolated  between  the  root  of  the  nose  and  its 


RHINOPLASTY 


207 


lobule.     The  internal  surface  of  the  interpolation  is  lined  with  skin 
and  so  is  the  exterior. 

For  restoring  the  alae  or  the  lobule  of  the  nose,  lost  by  frostbite, 
cauterization,  or  excision,  flaps  may  be  taken  from  the  cheeks,  the 
lips,  or  even  the  chin.     In  some  instances  pedunculated  flaps  from 


Fig.  212. — End  of  the  nose  destroyed  by 
caustics. 


Fig.  213. — Repair  of  end  of  nose  with  flaps 
taken  from  the  cheek. 


Fig.  214. — Same  case  after  completion  of  operation.     {Author's  patient.) 

the  arm  or  hand  may  be  utilized,  if  the  constrained  posture  of  this 
procedure  is  not  deemed  undesirable. 

The  Bayer-Payr  method  cuts  flaps  from  the  sides  of  the  chin  and 
turns  them  up  to  make  alee  and  columella. 

The  new  alse  may  be  lined  with  mucous  membrane  dissected  from 


208 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


the  nasal  septum  or  inner  surface  of  the  lower  lip  or  repaired  with  a 
flap  from  the  cheek  with  the  skin  surface  turned  inward.  Thiersch 
grafts,   Krause  free  flaps,   or  small  pedunculated  skin  flaps,  thrust 


Fig.  215.  Fig.  216. 

Figs.  215  and  216. — Lobule,  columella  and  alae  formed  from  flaps  cut  from  lower  part  of  the  cheeks. 
At  a  later  operation  the  base  of  the  flaps  are  cut  and  the  alae  are  set  nearer  the  columella  to  make 
proper  nostrils.     {Bayer-Payr's  method.) 


Fig.  218.- 


FiG.   217.  Fig.   218. 

Fig.  217. — Columella,  or  lower  part  of  septum,  made  from  web  of  thumb. 
-Charles  Nelaton's  method  of  forming  a  columella  by  detaching  with  gouge  the  nasal 
spine  and  part  of  the  vomer  and  bending  it  forward. 


through  buttonholes  in  the  skin,  may  be  used  in  this  endeavor.  The 
ala  needs  to  be  stiff  enough  not  to  collapse  during  inspiration.  A 
slip  of  cartilage  taken  from  the  ear  may  be  inserted,  or  scales  of  car- 
tilage cut  from  the  costal  cartilages  may  be  employed. 


RHINOPLASTY 


209 


I  have  stiffened  the  columella  of  a  soft  nose  by  inserting  a  peg  of 
cartilage  cut  from  the  tip  of  the  eighth  left  costal  cartilage.  This 
gave  the  lobule  the  proper  projection  forward.     The  same  thing  was 


Fig.  219.  1 1&    220 

Figs.  219  and  220. — To  make  ala  of  nose  from  cheek  and  upper  lip. 

done  by  von  Mangold^  in  an  endeavor  to  give  support  to  the  dorsum 
of  a  saddle  or  sunken  nose,  which  needed  rigiditv  of  the  raised  or  con- 


FlG. 


221. — To  make  ala  from  side  of  nose 
•with  pedicle  on  cheek. 


Fig.  222. — Septal  flap  to 
line  new  ala  and  avert  cicatri- 
cial occlusion  of  nostril. 


structed  area,  between  the  nasal  bones  and  its  tip.  The  columella 
may  be  made  from  two  vertical  flaps  cut  from  the  upper  lip,  one  on 
each  side  of  the  median  line,  involving  only  a  j^art  of  the  thickness  of 
the  lip.  The  entire  thickness  of  the  upper  lip  may  be  similarly  em- 
^  See  Bryant  and  Buck,  "American  Practice  of  Surgery,"  vol.  iv,  p.  70S. 

14 


210 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


ployed  for  a  single  median  flap.  Longitudinal  labial  flaps  may  be 
chosen,  or  the  tissues  of  the  forearm  or  arm  may  be  used  or  that  be- 
tween the  thumb  and  forefinger  may  be  grafted  into  the  gap,  by  apply- 
ing the  hand  to  the  chin  for  about  two  weeks.     A  portion  of  the  nasal 


Fig.   223.  Fig.   224. 

Figs.  223  and  224. — To  make  the  side  of  the  nose  and  an  ala  with  flaps  from  dorsum  of  nose  and  cheek. 

spine  of  the  upper  jaw  may  be  chiseled  loose  and  reflected  upward,  to 
give  rigidity  to  the  new  columella  which  is  to  be  constructed. 

Kolle  has  closed  defects  in  the  ala  of  the  nose  by  taking  a  free 


Fig.  225.  Fig.  226. 

Figs.  225  and  226. — Method  of  lengthening  short  nose  or  saddle  nose  and  restoring  nostrils  to 

horizontal  plane. 

cutaneo-cartilaginous  flap  from  the  back  of  the  ear.  The  flap  is  cut 
vertically  and  includes  a  strip  of  cartilage  about  the  size  and  shape  of 
the  deficiency  in  the  nose.  This  flap  is  folded  and  sewed  into  the 
defect  so  as  to  have  a  skin  surface  on  both  the  outer  and  inner  aspects. 


RHINOPLASTY 


211 


To  construct  the  columella,  cartilage  with  a  pedicle  at  the  back 
may  be  obtained  from  the  quadrangular  cartilage  of  the  nasal  septum 
and  be  covered  with  a  labial  flap;  or  instead  a  free  flap  containing 
cartilage  may  be  cut  from  the  ear. 

A  large  and  bulbous  lobule  may  be  reduced  Ijy  cutting  out  a  wedge 


Fig.  227. — To  reduce  width  and  bulk  of  nasal  lobule. 

and  suturing  the  wound  neatly;  or  by  submucous  excision  of  the 

superabundant  subcutaneous  tissue.     An  elevated  lobule  is  drawn 

downward  by  excising  a  triangular  section  of  the  cartilaginous  septum. 

When  the  lobule  is  very  broad  at  its  base  and  concave  at  its  sides 


Fig.  228.  Fig.  229. 

Figs.  228  and  229. — To  reduce  size  of  nose  when  soft  parts  are  too  bulky.     Diagrams  show  lateral 

view  and  front  view. 

the  excision  of  an  angular  diamond  shape  piece  of  tissue  from  the 
anterior  angle  of  each  nostril  will  correct  the  deformit}'.  One  angle 
of  the  diamond  or  lozenge  is  near  the  tip  of  the  nose,  the  other  within 
the  nostril  at  the  front  of  that  opening  extending  upward  on  the 


212 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Fig.  230. — Miculicz's  method  of  reducing  lobule  and  alee  by  cutting  out  a  triangular   piece   of 
the  septum  CD,  folding  in  the  alte  from  B,  and  turning  back  point  A. 


Fig.  231. — Deviations  of  septum  from  old  fractures  of  nose.     {Mutter  Museuin.) 


RHINOPLASTY  213 

mucous  membrane.  The  diamond  incision  is  bent,  as  it  were,  on  the 
edge  of  the  opening  of  the  nose. 

Deformity  caused  by  undue  prominence  of  the  nasal  tip,  or  a  hook- 
like appearance  of  the  lower  end  of  the  lobule,  is  relieved  by  Kolle  in  a 
manner  somewhat  like  that  of  Miculicz  for  reducing  a  large  nose. 

He  cuts  away  the  redundant  lower  prominence  of  the  lobule  and 
the  adjacent  parts  of  the  septal  cartilage  and  columella,  leaving  a 
flap  of  the  anterior  part  of  the  lobule.  After  removal  of  sufficient 
portions  of  the  two  alae,  the  flap  of  lobule  is  bent  backward  and  sutured 
to  the  stump  of  the  columella.  Then  the  raw  surfaces  at  the  lower 
margin  of  the  wings  are  closed  with  sutures,  either  with  or  without 
further  excision  of  the  contained  cartilage. 

When  the  prominence  of  the  lobule  is  insufficient  it  may  be  ad- 
vanced by  the  Gensoul  method. 


I       .       .  

FiG.  232. — Diagram  to  show  how  fractures  of  nose  may  involve  contents  of  cranium. 

A  widened  base  of  the  nose  may  be  reduced  by  excision  of  wedges 
just  within  the  nostrils. 

If  the  wings  are  too  thick,  wedges  or  pegs  of  tissue  may  be  cut  out. 

Abnormal  or  unsightly  prominences  of  the  nasal  bones  or  the 
nasal  processes  of  the  maxillae  should  be  removed  from  within  the 
nose,  with  saws  or  drills  and  forceps,  through  submucous  incisions;  or 
with  chisels  after  exposure  through  oblique  incision  of  the  overlying 
skin. 

Prosthetic  Appliances  for  Nasal  Deficiencies. 

Portions  of  the  nose  made  of  wax,  porcelain,  aluminum,  vulcanite, 
or  celluloid,  properly  colored,  are  at  times  used.  Vulcanite  is  most 
serviceable.  Porcelain  is  probabl}^  the  best  material,  but  it  is  difficult 
to  manipulate  except  by  very  skilful  artificers  in  that  material. 
Celluloid  is  inflammable  and  may  warp.     Most  metals  are  too  heavy. 


214  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

Aluminum  is  light,  but  it  is  said  that  metals  do  not  hold  well  the 
paint  necessary  for  coloring. 

Artificial  noses  are  held  in  place  by  means  of  spectacle  frames  and 
by  additional  support  from  the  floor  of  the  nasal  chambers.  Some- 
times expanding  springs  within  the  nose  are  used  for  maintaining  the 
apposition  of  the  false  nose  to  the  face.  Uncomfortable  intranasal 
pressure  must  in  all  these  cases  be  avoided  by  giving  widely  distributed 
pressure;  and  the  prosthetic  appliance  simulating  a  nose  must  be 
readily  removable  and  so  constructed  as  to  show  as  little  as  possible 
the  line  of  junction.  Occasionally  the  adjoining  portions  of  the  face 
need  to  be  artificially  represented.  The  nose  with  the  lip  or  cheek 
are  then  constructed  as  one  piece.  If  the  palate  is  perforated,  the 
support  may  be  obtained  partly  by  attachments  to  the  teeth.  As  a 
rule  surgical  restorations  are  better  than  artificial  representations  of 
the  nose. 


CHAPTER  XV. 

DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL. 

Congenital  Deformities. 

Congenital  deformities  of  the  eyelids  may  demand  surgical  inter- 
vention. Total  or  partial  absence  of  the  lids,  clefts,  fistules,  adhesions 
to  each  other  or  to  the  eyeball,  abnormal  inversion  or  eyersion,  im- 
perfect closure  of  the  palpebral  opening,  drooping  of  the  upper  hd, 
and  the  presence  of  a  fold  of  skin  extending  over  the  inner  angles  of 
the  ocular  openings,  called  epicanthus,  are  the  defects  of  natal  origin 
likely  to  be  brought  to  an  operator's  attention. 


Fig.  233. — Levis's  case  of  anophthalmos  or  absence  of  eyeballs. 

Partial  or  total  absence  of  the  organ  of  sight  may  occur.  The 
congenital  anomaly  then  involves  the  eyeball  and  may  be  associated 
with  absence  of  the  lids  and  of  the  conjunctival  sac.  The  skin  of  the 
forehead  and  cheek  is  continuous,  concealing  beneath  it  a  rudimentary 
eyeball,  or  orbital  structures  which  contain  no  globe  of  the  eye. 

The  only  instance  of  congenital  absence  of  the  eyelids  which  I 
have  seen  was  that  described  by  Dr.  L.  Webster  Fox.  The  child, 
aged  five  months,  in  whom  there  were  no  eyebrows,  showed  in  each 
eye  the  skin  from  the  forehead  continuous  over  the  orbital  ridge  to  the 
conjunctiva  and  cornea,  where  it  ended  in  a  pointed  flap  adherent  to 

215 


216 


SURGERY  OF  DEFORMITEIS  OF  THE  FACE 


the  globe.  A  small  piece  of  tarsal  cartilage  could  be  detected  in  the 
deficient  upper  lid  in  one  eye.  The  lower  lids  of  both  eyes  were 
normal.  The  corneae  were  opaque  except  that  in  the  lower  part  of 
one  there  was  an  area  of  translucent  tissue.  The  infant,  which  was  a 
male,  seemed  to  have  perception  of  light. 

Cleft  of  the  eyelid  may  have  a  thin  membrane  stretching  across 
the  fissure  from  one  border  to  the  other.  Incisions  to  remove  this 
web-like  structure  and  to  freshen  the  margins  of  the  notch  may  be 


f 

•^1^ 

■ 

h 

^B^" 
-C-.- 

'^«hK 

^ 

\ 

^ 

■ 

if 

r  ^ 

Fig.  234. — Congenital  cyst  of  the  lower  lid,  with  microphthalmos. 


made,  and  be  followed  by  suturing  to  maintain  apposition  until 
healing  occurs.  If  no  web  is  present,  the  edges  are  simply  made  raw 
and  sutured. 

Congenital  bands  holding  the  edges  of  the  upper  and  lower  lids 
together  at  the  angles  of  the  eye  or  stretching  across  the  palpebral 
opening  from  the  middle  of  one  lid  to  the  other  should  be  divided  or 
removed.  The  margins  of  the  eyelids  should  then  be  repaired  by 
using  fine  sutures. 

Congenital  attachments  of  the  lids  to  the  eyeball,  such  as  that 
described  above  in  Fox's  case  of  partial  absence  of  the  upper  lids,  and 
other  forms,  which  may  be  met,  should  be  treated  by  operations 
similar  to  those  employed  in  the  correction  of  adhesions  acquired 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL 


217 


from  burns  and  other  injuries.  The  operations  for  eversion  and  inver- 
sion of  the  eyelids,  for  drooping  of  the  upper  eyelid  and  for  imper- 
fect closure  of  the  eyes  are  like  those  adapted  to  these  conditions  due  to 
pathological  lesions  occurring  in  post-natal  life.     The  surgeon  must. 


Fig.  235. — Cyst  of  upper  eyelid. 


however,  bear  in  mind  the  possibility  of  defects  in  muscular  control  of 
the  lids  in  infancy  being  due  to  imperfect  innervation.  Sometimes 
the  paresis  or  paralysis  is  due  to  obstetric  injuries  of  nerves  or  to  the 
brain  being  imperfectly  developed. 


Fig.  236. 


-Angeioma  of  upper  lid  cured  by  excision,  injection  of  boiling  water  and  transference 
of  flaps.     (Author's  patient.) 


The  occurrence  of  congenital  protrusions  of  the  meninges  of  the 
brain  or  the  brain  itself  through  defects  in  the  cranial  bones  near  the 
eyes  must  be  remembered  when  one  is  about  to  operate  on  swellings 
in  the  vicinity  of  the  eyelids.  Cysts,  angeiomas,  lymphangeiomas, 
warts,  horny  tumors,  elephantiasis,  dermoid  tumors,  neuromas,  malig- 
nant growths  and  sj'philitic  gummas  are  found  in  the  eyelids  and  orbit. 
These  and  other  swellings  require  treatment  like  analagous  conditions 


218 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


elsewhere;  but  efforts  should  be  made  to  remove  them,  when  opera- 
tion is  demanded,  in  a  manner  which  will  cause  little  interference 
with  the  movement  and  appearance  of  the  lids  and  eye  itself.  Plastic 
restoration  of  the  appendages  of  the  eye  may  be  required  after  the 
excision. 

For  operative  work  on  the  eyelids  and  eyeball,  knives,  scissors, 
forceps  and  needles  which  are  small  are  essential.  Tumors  of  the 
lids,  such  as  cysts,  may  often  be  removed  by  incision  on  the  mucous 
surface  of  the  lid.  At  other  times  the  cut  can  be  made  more  satis- 
factorily through  the  skin.  In  either  case  it  is  convenient  to  control 
bleeding  and  steady  the  eylid  by  grasping  it  with  a  special  pressure 
clamp  before  making  the  incision. 


Fig.  237. — Plastic  operation  on  eyelids  after  excision  of  cutaneous  hypertrophy 
(elephantiasis).      (Author's  patient.) 

If  this  is  not  an  easily  obtainable  instrument,  the  lid  may  be 
steadied  by  grasping  its  edge  with  a  pair  of  small  rat-tooth  forceps  or 
making  it  tense  with  a  flat  spatula  pushed  underneath  it. 

Sometimes  a  swelling  of  the  lids  occurs  from  edema  of  the  lymph 
vessels.  This  may  be  solid  and  resemble  an  infiltrating  tumor.  A 
soft  swelling  of  a  non-inflammatory  character  evidently  due  to  dis- 
tention of  the  lymphatic  channels  is  seen  occasionally  in  the  skin  of 
the  eyelids.  It  is  due  to  some  general  condition  needing  treatment, 
and  does  not  require  surgical  intervention.  Syphilitic  lesions  here  as 
in  the  nose  should  be  recognized  and  promptly  treated  with  medicinal 
remedies. 

Epicanthus  has  been  mentioned  under  deformities  of  the  nose. 
The  crescentic  fold  of  skin  overlying  the  internal  canthus  of  the  pal- 
pebral fissure  may  be  displaced  toward  the  nose  by  one  of  the  plastic 
operations  there  described. 


DEFORMITIES  OF  THE   EYELIDS  AXD   EYEBALL 


219 


A  section  of  skin  the  shape  of  an  arrow  head,  with  the  point  toward 
the  nose,  is  excised  from  each  of  the  voluminous  fokls  concealing  the 
inner  angles  of  the  eyelids.  The  application  of  sutures  draws  the 
superabundant  integument  away  from  the  eye  and  the  deformit}'  is 
permanently  relieved.  This  operation  is  indicated  in  those  cases  of 
epicanthus  which  are  too  marked  to  be  relieved  by  the  excision  of  a 
vertical  ellipse  of  skin  from  over  the  bridge  of  the  nose. 

A  rare  anomaly  is  the  presence  of  a  fold  of  skin  extending  from  the 
brow  to  the  malar  region,  so  as  to  cover  the  external  angle  of  the 
eyelids.  To  it  the  term  external  epicanthus  has  been  applied.  It 
should  be  treated  by  a  plastic  operation  similar  to  that  just  described. 

Bilateral  internal  epicanthus  may  give  the  impression  to  an  in- 
experienced observer  that  internal  strabismus  exists.  The  deviation 
of  the  eyeballs  is,  however,  only  apparent,  as  will  be  quickly  recog- 
nized by  careful  inspection.  Congenital  ptosis,  or  drooping  of  the 
upper  lid,  is  a  not  infrequent  accompaniment  of  internal  epicanthus. 

Ptosis. 

Congenital  ptosis  does  not  result  in  the  patient's  eye  or  eyes  being 
entirely  closed,  but  there  is  an  inability  to  lift  the  upper  lid  sufhciently 


FiG.  238. — Thread  operatioa  for  ptosis. 

to  completely  uncover  the  cornea.  It  is  said  that  some  elevation  of 
the  drooping  lid  takes  place  when  the  eye  is  adducted  or  abducted  or 
the  mouth  opened  and  that  contraction  of  the  pupil  then  occurs. 

Ptosis  may  be  due  to  a  redundancy  of  tissue  or  to  the  presence  of 
fatty  or  other  growths  in  the  Hd  giving  it  increased  bulk  or  weight. 
In  the  characteristic  congenital  variety  there  is  imperfect  develop- 
ment or  absence  of  the  elevator  muscle  of  the  lid  or  a  deficiency  in  its 
innervation  Ijy  the  nerve  twig,  which  comes  to  it  from  the  third 
cranial  nerve. 


220 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Drooping  of  the  lid  from  infiammatory  causes,  from  increased 
weight  due  to  tumors,  and  from  senile  atrophy  of  the  elevator  muscle 
is  not  considered  to  be  true  ptosis.  Acquired  ptosis  occurs,  of  course, 
in  cerebral  or  peripheral  disease  involving  the  whole  of  the  third 
cranial  nerve  or  the  branch  supplying  the  elevator,  of  the  upper  lid. 
In  such  instances  the  immobility  of  the  upper  lid  and  the  covering  of 
the  cornea  is  more  likely  to  be  complete  than  in  congenital  ptosis. 
Many  instances  are  syphilitic.  The  bilateral  drooping  of  the  upper 
eyelids  often  seen  in  hysteria  must  not  be  mistaken  for  ptosis  requiring 
operative  treatment. 

If  it  is  found  that  medicinal  treatment  even  when  combined 
with  the  local  use  of  electricity  has  been  ineffectual  in  relieving  ptosis, 
operative  attack  is  proper.  The  natural  elasticity  of  the  skin  of  the 
lid  and  the  deficient  power  of  the  elevator  muscles  in  many  cases 


Fig.  239. — Tansley's  operation  for  ptosis. 


make  the  permanency  of  the  surgical  improvement  often  disappoint- 
ing. Many  operations  have  been  employed  to  give  the  patient  control 
of  the  lid.  The  impossibility  of  opening  the  eye  completely  is  not 
only  a  disfigurement,  but  may  interfere  with  the  vision  of  the  eye 
or  eyes  from  the  pupil  being  covered  continually. 

The  removal  of  a  transverse  ellipse  of  skin,  with  the  subcutaneous 
connective  tissue,  from  the  drooping  lid  would  seem  to  be  indicated. 
This  procedure  is  of  little  permanent  service,  however,  even  if  some  of 
the  fibers  of  the  orbicular  muscle  be  excised  with  the  skin  and  sub- 
cutaneous structures,  unless  the  amount  of  the  ptosis  is  very  slight. 
Fair  success  in  moderate  degrees  of  ptosis  may  be  obtained  by  remov- 
ing not  a  narrow  ellipse  of  skin  and  subcutaneous  fascia,  but  a  wide 
section  of  these  structures,  which  has  a  convex  upper  border  near  the 
bony  margin  of  the  orbit  and  an  almost  horizontal  border  from  right 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL  221 

to  left  along  the  free  edge  of  the  lid  close  to  its  lashes.  Some  fibers 
of  the  orbicular  muscle  and  a  narrow  elliptical  strip  of  the  tarsal 
cartilage  itself  should  be  cut  out.  The  area  of  tissue  to  be  cut  away 
from  the  drooping  lid  is  the  difference  between  its  length  and  that  of 
the  normal  lid. 

The  occipito-frontal  muscle  must  be  utilized  to  lift  the  drooping 
upper  lid  in  those  cases  in  which  the  elevator  of  that  structure  is 
absent  or  paralyzed.  This  may  be  done  by  causing  the  formation  of 
cicatricial  bands  of  fibrous  tissue,  beneath  the  skin  of  the  lid.  These 
will  connect  the  lower  portion  of  the  lid  with  fibers  of  the  frontal 
portion  of  the  occipito-frontal  muscle.  This  object  may  be  accom- 
plished hj  carrying  two  or  three  subcutaneous  mattress  sutures  from 
the  region  just  above  the  lashes  to  a  point  above  the  eyebrow.  Each 
thread  is  introduced  from  below  upward  by  means  of  a  straight  needle 
on  each  end.  The  suture  is  tied  over  a  little  piece  of  fine  rubber 
tubing,  after  the  falling  lid  has  been  drawn  up  sufficiently  to  correct 
the  deformity.  The  sutures  may  be  untied  and  tied  a  little  more 
tightly  every  few  days,  until  they  cut  their  way  through  the  sub- 
cutaneous tunnels  leaving  scar  tissue  in  their  tracks. 

A  more  direct  attachment  of  the  frontal  muscular  fibers  to  the 
upper  lid  may  be  obtained  by  raising  a  vertical  tongue  of  skin,  from 
the  surface  of  the  lid  at  its  center,  which  is  carried  through  a  sub- 
cutaneous tunnel  under  the  eyebrow.  It  is  stitched  to  the  frontal 
muscular  belly,  after  sufficient  skin  and  fascia  have  been  dissected  from 
the  skin  of  the  lid  to  make  the  depth  of  the  affected  lid  correspond  to 
a  normal  upper  eyelid.  All  of  the  sutures  are  then  neatly  united  by 
sutures.  The  tongue  should  have  the  part  of  its  skin  surface  which 
is  to  be  buried  denuded  of  the  epithelium. 

Instead  of  using  this  tongue  of  skin  to  make  the  connection,  it 
would  seemingly  be  easy  to  dissect,  through  an  incision  on  the  fore- 
head, a  band  of  muscle  and  carry  it  through  a  tunnel  to  be  stitched 
to  the  tarsal  cartilage,  in  a  manner  similar  to  the  method  of  trans- 
planting tendons  of  the  hand  and  foot. 

A  more  elaborate  operation  than  those  described  utilizes  a  small 
strip  of  tendon  taken  from  the  superior  rectus  muscle  of  the  eyeball. 
This  is  cut  from  the  middle  of  that  tendon,  after  incising  the  con- 
junctiva. It  is  carried  up  through  the  under  surface  of  the  everted 
upper  lid  and  its  elevator  tendon,  near  the  upper  margin  of  the  tarsal 
cartilage,  by  means  of  a  mattress  suture  with  a  small  needle  on  each 
end.  The  end  of  the  tendon  to  be  transplanted  is  then  drawn  into  a 
pocket  prepared  for  it  and  is  attached  to  the  tarsal  cartilage  near  the 
insertion  of  the  tendon  of  the  weak  elevator  of  the  lid.     Finallv  the 


222  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

two  ends  of  the  suture  are  brought  through  the  skin  of  the  upper  lid  at 
points  sHghtly  separated  from  each  other  and  are  tied.  This  opera- 
tion requires  considerable  operative  skill  and  leaves  for  a  time  double 
vision  due  to  the  post-operative  weakness  of  the  muscle  which  rolls 
the  eyeball  upward. 

Perhaps  a  better  method  in  the  severe  cases  of  ptosis  is  that  which 
shortens  the  suspensory  ligament  of  the  lid  by  means  of  two  buried 
mattress  sutures.  By  these  stitches  the  tarso-orbital  fascia  and  the 
tendon  of  the  elevator  muscle  are  shortened  by  making  horizontal 
gathers.  These  structures  are  uncovered  by  a  horizontal  cut  about 
two  inches  long  upon  the  upper  orbital  ridge  just  within  the  eyebrow. 
The  skin  and  orbicular  muscle  are  raised  to  expose  the  tarsal  cartilage 
and  its  suspensory  fascia.  Two  silk  or  chromicized  catgut  mattress 
sutures  are  then  introduced  through  the  cartilage  near  its  upper  edge, 
are  carried  upward  through  the  suspensory  ligament,  or  fascia,  and 
the  tendon  of  the  elevator  muscle,  and  are  then  tightened  and  tied. 
The  skin  wound  is  closed  over  the  knots  after  the  stitches  have  shown 
that  the  suspensory  ligament  and  aponeurosis  of  the  weak  elevator 
muscle  have  been  shortened  enough. 

Changing  the  Size  of  the  Palpebral  Opening. 

Because  of  malformations  of  the  lid,  paralysis  of  the  orbicular 
muscle,  or  protrusion  of  the  eyeball,  it  may  be  necessary  to  make  a 
smaller  palpebral  opening.  This  should  not  be  done  for  cosmetic 
reasons  unless  the  palsy,  the  exophthalmic  goiter,  or  other  general 
cause  has  been  cured,  or  at  least  relieved  as  much  as  is  likely  to  be 
possible,  by  medical  treatment. 

Suture  of  the  external  canthus  is  a  simple  procedure  and  greatly 
relieves  the  staring  look  often  remaining  after  attacks  of  exophthalmic 
goiter.  It  is  not  available  when  the  exophthalmos  is  due  to  orbital 
tumors  or  abscess.  Then  extirpation  or  evacuation  with  drainage 
is  the  operation  through  which  to  seek  cure.  Tarsorrhaphy,  or 
-suture  of  the  external  canthus,  narrows  the  opening  of  the  eye  and  is 
done  in  two  ways. 

The  first  cuts  away  with  knife  or  scissors  the  muco-cutaneous 
margin  of  each  lid,  with  the  hair  follicles  of  the  lashes,  for  from  3  to  5 
millimeters  from  the  external  angle  of  the  eye.  Sutures  are  used  to 
unite  these  denuded  borders.  To  prevent  the  union  failing  at  the 
internal  end  of  the  suture  line,  it  is  well  to  denude  the  inner  edge  of 
the  lids,  without  removing  the  lashes,  for  a  short  distance  beyond  the 
extremity  of  the  excised  flaps. 


DEFORMITIES  OF   THE   EYELIDS  AND   EYEBALL  223 

In  the  second  method  the  lower  lid  is  split  at  the  external  canthus 
by  an  intermarginal  incision  and  an  incision  at  right  angle  to  the 
inner  end  of  the  first  cut  creates  a  skin  flap.  The  corresponding  part 
of  the  upper  lid  is  denuded  of  mucosa,  skin,  and  lashes.  A  mattress 
suture  is  then  used  to  draw  the  flap  attached  to  the  lower  eyelid  over 
the  raw  area  on  the  upper  lid  and  the  palpel^ral  opening  is  thus  made 
smaller. 

If  the  opening  of  the  lids  is  too  small  it  may  be  enlarged  by  a 
canthoplasty.  In  this  operation  the  junction  of  the  lids  at  the  outer 
angle  of  the  eye  is  divided  by  scissors  or  knife  to  the  requisite  extent 
in  a  horizontal  direction.  The  cut  includes  the  conjunctiva,  muscle 
and  skin.  The  lids  are  separated  by  tension  of  the  fingers  of  an 
assistant  or  by  an  eye  speculum  and  the  margins  of  the  conjunctiva 
and  skin  are  stitched  together  in  the  vertical  direction.  This  opera- 
tion may  be  of  value  in  making  the  eye  look  larger,  when  the  condition 
called  enophthalmos  is  present  from  injury  of  the  bones  causing  the 
orbit  to  be  deepened  or  depressed  and  the  eye  to  drop  backward. 

Cicatricial  narrowing  of  the  ocular  aperture  will  occur  after  excision 
of  growths  at  the  external  angle  or  that  opening  may  need  to  be 
enlarged  after  such  scar  contraction  has  already  occurred  from  burns 
or  other  traumatisms.  Plastic  reconstruction  of  the  angle  will  be 
required  to  reconstruct  the  palpebral  opening  in  these  conditions. 
This  may  be  done  by  cutting  a  forked  or  split  temporal  flap  with  its 
pedicle  below,  and  rotating  it  through  an  arc  of  90°.  Its  points  should 
be  sutured  to  the  upper  and  lower  lids  after  excising  the  tumor  or 
cutting  awa}"  the  scar  tissue. 

Adhesions  of  Lids. 

Adhesion  of  the  margins  of  the  eyelids  to  each  other  may  occur 
along  their  entire  length  or  in  any  portion  of  their  extent.  The  con- 
dition is  sometimes  congenital.  The  acquired  variety  of  ankylo- 
blepharon is  usually  the  result  of  burns  from  acids,  alkaline  caustics, 
or  heat,  though  it  vaay  occur  from  inflammatory  destruction  or  ulcera- 
tion of  the  normal  surface  of  the  margins  of  the  eyelids. 

An  allied  condition  of  similar  origin  and  treatment  is  adhesion  of 
one  or  both  lids  to  the  ocular  conjunctiva  or  the  surface  of  the  cornea. 
This  is  called  sjmiblepharon.  Ankyloblepharon  and  symblepharon 
ma}^  co-exist  in  the  same  eye. 

When  the  two  lids  are  connected  by  bands  at  their  borders,  in- 
cision to  divide  the  intervening  tissue  may  be  all  that  is  necessary.  If 
they  are  fused   together  by  wide   adhesion   of  previously  ulcerated 


224 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


surfaces,  the  result  of  extensive  injury  or  disease,  the  surgeon  may  be 
obliged,  after  cutting  them  apart,  to  cover  the  raw  margins  with 
pedunculated  flaps  of  conjunctiva  turned  up  or  down  from  the  surface 
of  the  eyeball.  Thin  skin  flaps  from  the  temple,  grafts  from  the 
post-auricular  integument  or  mucous  grafts  from  the  inner  surface 
of  the  lower  lip  may  be  employed.  Such  operations  are  in  effect  cases 
of  restoration  of  part  of  a  lid.  The  restoration  is  usually  defective 
in  providing  no  eyelashes. 


Fig.  240. — Arit  symblepharon  operation.     The  drawing  shows  the  adhesion  dissected. 

In  adhesion  of  a  lid  to  the  eyeball,  similar  flap  or  graft  operations 
are  usually  demanded.  Sometimes  the  symblepharon  is  so  limited 
that  the  raw  area  left  after  separation  of  the  lid  from  the  globe  may  be 
covered  by  simply  drawing  the  conjunctiva  over  it  with  sutures,  after 
a  little  undercutting  to  make  it  movable.  In  other  instances  the 
pedunculated  mucous  flaps  of  conjunctiva  are  displaced  by  sliding, 
folding  and  torsion  in  the  manner  which  is  employed  in  using  sldn 
flaps  in  plastic  procedures  to  cover  cutaneous  wounds.  Sometimes 
the  adherent  portion  of  lid  may  be  dissected  from  the  eye  and  be 
turned  by  a  mattress  suture  into  the  groove  between  the  base  of  the 


DEFORMITIES  OF  THE  EYELIDS  AND   EYEBALL 


225 


eyelid  and  the  ball.  If  it  is  stitched  in  this  inverted  position,  it  will 
present  its  cutaneous  surface  toward  the  ball,  where  the  latter  is  left 
uncovered  by  conjunctiva  or  epithelium.  The  latter  area  is  covered 
with  conjunctival  flaps  or  grafts.  Repetition  of  adhesion  is  thus 
made  unlikeh'. 

Harlan's  method  for  complete  symblepharon  of  the  lower  lid  is 
worth}'  of  description. 

After  the  adhesion  to  the  globe  has  been  completely  divided  so 
that  the  lid  and  the  eyeball  have  no  restriction  in  mobility,  the  lid 
is   detached   from   the   orl;)ital   marein   bv   a   horizontal   button-hole 


Fig.  241. — Aril  symblepharon  operation  completed. 

incision  through  the  skin.  This  cut  makes  a  bridge  of  the  lid,  fastened 
to  the  adjacent  structures  at  its  ends  only.  Through  this  button-hole 
a  short  but  wide  flap  of  skin,  cut  from  the  front  of  the  face,  is  turned 
up  and  stitched  to  the  raw  inner  surface  of  the  lower  lid.  This  pro- 
cedure lines  the  eyelid  with  skin,  which  has  its  epidermis  toward  the 
wound  left  on  the  globe  of  the  eye  by  the  antecedent  detachment  of 
the  lower  lid.  The  wound  of  the  face  is  closed  more  or  less  completely 
by  sliding  skin  from  the  cheek,  and  the  raw  surface  on  the  eyeball 
may  be  covered  with  conjunctival  flaps  or  grafts,  or  with  Thiersch 
skin  grafts  cut  from  the  thigh  or  arm.  Care  must  be  taken  to  have  a 
good  blood  supply  for  the  everted  flap,  which  is  thrust  through  the 
button-hole.     Hence  it  is  well  to  have  some  muscular  tissue  in  the 


226 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


flap  where  its  hinge  is  made  and  to  have  a  sufficient  space  between 
the  incision  which  cuts  the  flap  and  the  incision  going  through  the 
substance  of  the  lid. 

The  raw  surfaces  left  after  dividing  a  symblepharon  may  be  covered 
with  Thiersch  skin  grafts,  or  mucous  membrane  grafts.  These  should 
be  stitched  to  the  conjunctiva  of  the  globe  and  to  the  margin  of  the 
lid.  They  may  be  held  more  accurately  in  place  by  inserting  a  glass 
or  metal  shell  over  the  eyeball.  This  will  press  the  graft  down  into 
the  oculo-palpebral  groove  and  maintain  apposition  of  the  applied 
raw  surfaces.     A  semilunar  lead  disk  cut  to  fit  the  groove  and  having 


Fig.  242. — Adams  ectropion  operation. 


Fig.  243. — Adam's  ectropion  opera- 
tion, sutures  tied.  The  pin  suture  is  not 
used  now. 


holes  by  which  it  may  be  stitched  to  the  margin  of  the  lid  and  to  the 
graft  is  a  satisfactory  device.  The  skin  or  mucous  graft  and  disk 
should  be  adjusted  by  sutures  to  the  edge  of  the  eyelid.  Then  the 
two  lids  should  be  closed  with  care  and  a  compress  lightly  bound  over 
the  eye.  The  eye  need  not  be  examined  for  two  or  three  days,  and 
the  lead  plate  may  be  left  undisturbed  for  a  week. 

The  disfigurements  due  to  adhesions  of  the  lids  and  the  bulbar 
conjunctiva  should  always  be  remembered,  when  recent  injuries  of 
these  structures  are  first  seen.  Careful  suturing  and  applications 
to  prevent  contact  of  raw  surfaces  should  be  a  feature  of  the  treat- 
ment, when  ankyloblepharon  or  symblepharon  is  a  possibility. 


Eversion  of  the  Eyelids. 

Either  of  the  lids  may  be  turned  out  so  as  to  expose  the  mucous 
surface.  The  lower  lid  is  the  more  frequent  seat  of  the  displace- 
ment. An  overflow  of  tears  is  apt  to  occur,  if  the  lower  lid  be  afTected. 
Chronic  eversion  is  followed  by  thickening  of  the  mucous  membrane. 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL 


227 


The  cornea  may  become  ulcerated  because  its  surface  is  not  kept 
free  of  irritating  particles  by  means  of  the  normal  wiping  of  its  sur- 
face by  the  close-fitting  lids. 

Ectropion  of  the  lids  may  be  caused  by  loss  of  power  in  the  orbic- 
ular muscle,  as  in  palsy  of  the  facial  nerve  and  in  the  weakness  of  the 
muscle  fibers  incident  to  old  age.     It  results  also  from  traction  of  scar 


fe^^; 


Fig.  244. — Strap  flap  from  temple  to  lift  up  lower  lid.     The  skin  within  the  dotted  line  is  cut  away 
to  make  a  raw  surface  and  the  strap-like  flap  is  then  sutured  over  the  raw  space. 

tissue  on  the  front  of  the  lid,  and  from  pressure  from  behind,  as  in 
exophthalmos,  in  tumors  of  the  eyeball  and  in  growths  of  the  con- 
junctiva or  lid  itself. 

The  worst  deformities  of  this  character  are  seen  after  cicatricial 
contraction  has  occurred  subsequent  to  sloughing  due  to  burns  of  the 


Fig.  245. — V-flap  for  oblique  ectropion. 

cheek  and  forehead.  In  many  of  these  patients  portions  of  the  lids 
have  been  lost  by  the  gangrenous  process  and  fibrous  scar  tissue  has 
been  substituted  in  their  stead. 

Eversion,  due  to  simple  inflammatory  swelling  of  the  mucous 
membrane  lining  the  lid  may  be  cured  by  scarifying  the  swollen  mucosa 
and   treating  the   conjunctivitis  with   astringent   solutions.     If  the 


228 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


conjunctiva  is  the  seat  of  a  chronic  thickening,  which  causes  e version 
a  wedge  shape  strip  of  that  mucous  membrane  may  be  excised.     The 
strip  should  be  cut  across  the  whole  width  of  the  lid  from  canthus  to 
canthus.     In  some  cases  of  more  marked  ectropion  this  wedge  should 
include  the  tissues  below  the   conjunctiva  just  within  the  lashes. 


Fig.  246. — V-flap,  excision  ot  wedge  of  tarsus  and  canthoplasty 

After  its  excision  the  lid  should  be  turned  inward  by  two  or  three 
mattress  sutures.  This  is  similar  to  the  method  used  by  L.  Webster 
Fox.  In  mild  cases  of  e version  of  the  lower  lid  from  relaxation  a  neat 
operation  is  that  which  makes  a  horizontal  cut  through  the  skin  just 
above  the  level  of  the  rim  of  the  orbit,  and  goes  through  the  muscle 


Fig.  247.— Temporal 


to  correct  ectropion. 


until  the  mucous  membrane  lining  the  internal  surface  of  the  lid  is 
reached.  This  is  divided  in  the  same  horizontal  line  at  the  groove 
made  by  its  reflection  from. the  lid  to  the  eyeball.  The  front  edge  of 
the  mucosa  is  then  drawn  down  into  the  wound  made  in  the  tissues 
of  the  base  of  the  lid  and  stitched  into  the  cutaneous  woimd.  This 
dragging  of  the  mucosa  of  the  everted  lid  downward  and  a  little  for- 


DEFORMITIES  OF  THE  EYELIDS  AND   EYEBALL  229 

ward  into  the  skin  wound  suffices  to  invert  the  eyelid  and  thus  restore 
it  to  the  normal  position. 

If  the  lid  has  attained  increased  horizontal  length,  as  is  common 
when  the  eversion  has  lasted  a  long  time,  it  is  necessary  to  correct  the 
disproportion  in  size  as  well  as  to  turn  the  lid  inward.  A  wedge  taken 
from  the  border  of  the  lid  will  accomplish  this  end.  This  little  opera- 
tion is  sometimes  sufficient  to  cause  the  lid  to  hug  the  front  of  the  eye- 
ball without  any  other  step  to  decrease  the  eversion.  At  other  times 
this  cuneiform  excision  may  be  needed  in  addition  to  more  elaborate 
plastic  operations  to  overcome  the  turning  out  of  the  lid.  The  scar  of 
the  wedge  shape  wound  is  least  if  made  near  the  external  canthus. 
These  operations  are  applicable  to  eversion  of  the  lower  lid  rather  than 
to  the  upper  lid. 

The  strap  method  of  raising  the  lower  lid  when  everted  will  occa- 
sionally be  found  available.  In  this  operation  the  surgeon  lifts  the 
outer  end  of  the  lid  by  dissecting  a  long  vertical  tongue  of  skin  in 
the  temporal  region  and  attaching  its  free  end,  which  is  upward,  to  a 
higher  point  on  the  side  of  the  head  than  normal.  A  raw  surface  is 
made  there  by  excising  a  rectangle  of  skin. 

Galvano-puncture,  with  a  short  sharp  galvano-cautery  needle, 
through  the  mucous  membrane  into  the  tarsal  cartilage  will  cause 
sufficient  scar  contraction  to  invert  some  mild  grades  of  ectropion. 
The  lid  is  grasped  in  a  clamp  and  several  punctures  are  made  in  a 
horizontal  line  a  short  distance  behind  the  border  of  the  lid.  Ziegler 
has  advocated  this  method. 

When  the  ectropion  is  due  to  contraction  of  scar  tissue  pulling 
the  lid  away  from  the  eyeball,  the  lid  must  be  freed  from  the  displacing 
cicatrix  and  restored  to  its  normal  relation.  To  prevent  recurrence  of 
the  cicatricial  dragging,  transfer  of  the  tension  to  the  less  mobile  skin  of 
the  cheek,  or  the  interpolation  of  a  pedunculated  flap  or  of  a  graft  of 
skin  is  requisite. 

An  operation  often  efficacious  is  the  sliding  toward  the  eye  of  a 
V-shape  flap  of  skin,  cut  with  its  apex  sufficiently  distant  from  the  point 
of  greatest  displacement  of  the  lid  to  allow  correction  of  the  deform- 
ity. The  resulting  wound  is  closed  by  sutures  making  a  Y-shape  scar. 
This  procedure  transfers  the  tension  of  the  scar  from  a  more  or  less  ver- 
tical to  a  horizontal  direction.  The  pull  in  the  latter  direction  does  not 
displace  the  lid.  The  V-flap  must  be  made  with  its  legs  beginning 
close  to  the  lid  margin.  They  must  include  between  them  the  entire 
width  of  the  everted  part  of  the  eyelid.  The  whole  thickness  of  the 
skin  must  be  lifted,  and  the  dissection  should  be  carried  so  close  to 
the  orbital  ridge  that  the  everted  lid,  when  replaced  in  contact  with 


230 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Fig.  248. — Restoration  of  lid  by  the  Fricke  flap.     (Harlan.)     Everted  upper  lid  and  outline  of  : 


Fig.  249. — Operation  completed. 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL 


231 


the  ball  of  the  eye,  may  be  free  from  tendency  to  turn  outward  again. 
The  apex  of  the  V-flap  must  be  in  the  line  of  the  scar  tension. 

Sometimes  a  combination  of  the  sliding  V-flap,  excision  of  a  wedge 
from  the  margin  of  the  lid  and  a  canthoplasty  at  the  external  angle 
of  the  eye  are  needed  to  correct  the  ectropic  eyelid. 

When  the  eversion  is  great  or  when  the  cicatricial  character  of 
the  surrounding  skin  precludes  transfer  of  tension  by  sliding  toward 
the  eye  a  V-flap,  a  frontal  or  a  temporal  flap  with  a  pedicle  may  often 
be  used  with  advantage.  These  are  to  be  rotated  and  inserted  in  the 
gaps  left  after  the  ectropic  lid  has  been  replaced.  The  pedicle  of  such 
a  flap  is  divided  when  union  has  been  secured,  which  is  usually  at 
about  the  end  of  a  week  or  ten  davs. 


Fig.  250. — Bridge  flap  from  forehead  to  upper  eyelid. 

The  situation  from  which  a  flap  may  be  taken  to  cover  the 
raw  surface  left,  after  dissecting  loose  and  replacing  the  everted 
eyelid,  varies  with  the  character  of  the  skin  surrounding  the  eye. 
The  surgeon  must  determine,  before  he  begins  his  operation,  how  he 
will  close  the  wound  left  by  the  transfer  of  the  flap  which  he  expects  to 
utilize  to  distribute  the  cicatricial  tension.  He  may  for  this  purpose 
make,  by  a  series  of  cuts,  many  transfers  of  cellulocutaneous  tissue, 
or  he  may  use  Thiersch  skin  grafts,  or  free  flaps  of  the  whole  thickness 
of  the  skin.  The  methods  described  under  blepharoplasty  will  often 
be  required  to  complete  the  restoration  of  the  palpebral  region,  in 
bad  cases  of  ectropion. 


Restoration  of  Eyelids. 

"When  gangrene  or  injury  has  destroyed  the  greater  part  or  the 
whole  of  an  eyelid,  some  form  of  operation  to  make  a  new  lid  will 
claim  the  attention  of  the  surgeon.     These  more  extensive  blepharo- 


232 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


plastic  operations  are  valuable  and  important.  The  protection  given 
the  conjunctiva  and  cornea  by  the  lids  is  necessary  to  insure  freedom 
from  corneal  ulceration  and  probable  perforation.  Perforation  of  the 
cornea  leads  to  destruction  of  vision,  which  may  be  complete,  in  the 
eye  so  affected. 

Many  ingenious  devices  have  been  employed  in  blepharoplasty. 
The  illustrations  here  given  will  sufficiently  explain  the  general  prin- 
ciples on  which  the  upper  or  lower  or  both  lids  may  be  restored.  If 
after  the  repair  has  been  made  there  are  some  remains  of  the  orbicular 
muscle  to  enable  the  patient  to  close  his  eyelids,  or  enough  upper  lid 
to  permit  him  to  cover  the  cornea  by  rolling  the  eyeball  upward  by  its 
own  muscles,  his  condition  will  be  satisfactory,  even  though  eye- 
lashes have  not  been  preserved. 


Fig.  251. — Dieffenbach's  operation  for 
making  lower  eyelid. 


Fig. 


252. — Dieffenbach's  operation  for  making 
lower  eyelid  completed. 


Before  the  flap  which  is  to  constitute  the  new  eyelid  is  put  in 
position  the  remnants  of  the  injured  lid,  if  there  be  any,  must  be  read- 
justed and  vivified.  The  flap  which  is  transferred  or  transplanted 
should  have  a  raw  surface  for  its  new  bed  and  be  attached  by  sutures 
to  edges  of  living  skin.  The  rules  for  doing  aseptic  plastic  operations 
must  be  carefully  followed,  because  the  secretions  from  the  eye  may 
infect  the  wounds  and  suture  tracks,  even  when  the  circumstances 
are  otherwise  very  favorable.  I  usually  suture  Krause  skin  grafts, 
but  am  satisfied,  when  I  use  Thiersch  epidermic  flaps,  with  the 
pressure  of  dressings  to  keep  them  in  position. 

A  method,  which  has  merit  in  certain  cases,  is  that,  in  which 
a  two  pedicle  loop,  or  bridge  flap,  is  cut  from  just  above  or  below  the 
healthy  lid  if  the   skin  be  voluminous  enough.      The   flap   is  lifted 


DEFORMITIES  OF   THE  EYELIDS  AND   EYEBALL 


233 


across  the  palpebral  opening  and  sewed  in  the  gap  left  by  the  loss  of 
the  other  eyelid.  It  obtains  its  blood  supply  through  its  attached 
ends,  situated  close  to  the  outer  and  internal  canthus  respectively. 
After  the  new  skin  has  adhered  the  pedicles  are  divided  and  the 
tissue  near  each  canthus  is  reconstructed. 

In  obtaining  pediculated  flaps  for  extensive  plastic  repairs  of  the 
lids  it  is  frequently  necessary  to  make  many  transfers  to  relieve  the 


Fig.  253. — Condition  of  the  parts  two  months  after  modified  Dieffenbach  operation.     {Xorris.) 

resultant  scar  tension  which  is  caused  by  the  displacement  of  the 
first  flap.  The  operator  should  divide  tissues  freely,  provided  the 
proper  steps  are  clear  in  his  mind.  A  good  illustration  of  the  benefit 
of  such  operative  breadth  is  the  method  reported  by  Posey  and  Shum- 
way  for  creating  nearly  the  whole  of  both  eyelids. 

Free,  or  non-pedunculated,  flaps  may  be  used  with  much  satis- 
faction to  fill  spaces  left  by  the  sliding  of  flaps  to  make  new  lids,  to  pre- 
vent ectropion  after  removal  of  tumors,  or  to  complete  other  operative 
procedures.     The  thin  hairless  skin  of  the  inner  part  of  the  thigh  or 


234 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


Fig.  254. — Removal  of  growth  from  inner 
can  thus. 


Fig.  255. — Canthus   reconstructed  by  sliding 
flaps  above  and  below  orbit. 


Fig.  256. — Incisions  for  Hasner's  bleph- 
aroplasty. 


Fig.  257. — Hasner's  blepharoplasty  com- 
pleted. 


Fig.  258. — Fricke's  tongue  flap  for  tumor  of         Fig.  259.— Fricke's  flaps  for  tumor  of 
lower  lid.  lower  lid  sutured. 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL 


235 


arm  or  of  the  region  back  of  the  ear  may  be  used.  The  area  from 
which  the  flap  is  to  be  cut  must  be  sterilized  thoroughly  and  then 
bathed  in  sterile  physiological  salt  solution.  The  region  to  which 
it  is  to  be  transplanted  must  be  sterilized  and  similarly  bathed.  If 
it  is  a  raw  surface,  bleeding  should  be  checked;  if  an  ulcerated  surface, 
the  granulations  should  be  free  from  unhealthy  complications  and  be 
thoroughly  sterilized. 


Fig.  260. — Snydacker's  blepharoplasty  with  flap  from  neck. 


The  flap  should  consist  of  the  whole  thickness  of  the  skin  and  have 
all  the  fat  on  its  under  surface  entirely  clipped  away  with  sharp 
scissors.  Its  area  should  be  about  one-third  greater  than  the  space 
to  be  filled.  When  stitched  in  place  it  may  appear  too  thick  for  the 
purpose.  This  will  usually  be  corrected  by  the  changes  occurring 
later. 

A  dry  sterile  gauze  dressing  should  be  applied  with  moderate  pressure 
and  left  undisturbed  for  three  or  four  days.     When  a  new  dressing  is 


236 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


to  be  applied,  the  old  one  should  be  loosened  by  saturating  it  with 
sterile  salt  solution.  The  flap  and  the  adjacent  skin  should  be  dried 
with  sterile  cotton  and  a  new  dry  gauze  dressing  applied  and  left  in 
place  several  days.  Too  frequent  dressing  is  liable  to  be  detrimental 
by  displacing  the  flap  or  disturbing  the  adhering  edges.  No  antiseptics 
should  be  used  upon  it. 

Frequently  the  epithelium  and  the  underlying  cells  of  the  flap 
will  break  down  or  be  so  modified  by  what  appears  to  be  gangrene 
of  the  whole  flap  that  the  operator  will  be  disappointed.  In  a  short 
time,  however,  under  continued  application  of  sterile  dressings,  the 
parts  will  often  show  that  this  process  has  been  only  superflcial  and 


Fig.  261. — Temporal   flap    to    fill  space  under  eye  to  avert  cicatricial  ectropion  after  excision  of 

epithelioma.      (Author's  case.) 

that  the  lower  layers  of  the  skin  have  lived  and  will  close  the  wound 
without  cicatricial  contraction.  Occasionally  the  edges  of  the  flap 
at  places  may  die,  but  the  bulk  of  it  will  be  saved. 

Shavings  of  skin  may  be  used  instead  of  these  flaps  of  the  entire 
thickness  of  the  skin,  when  a  very  superficial  covering  of  a  raw  or 
ulcerated  surface  is  desired. 

Entropion,  or  inversion  of  the  eyelid,  is  a  distortion  which  causes 
much  annoyance  to  the  sufferer  without  producing  much  cosmetic 
deformity.  The  irritation  of  the  cornea  and  conjunctiva  induced  by 
the  constant  friction  of  the  lashes  growing  from  the  inturned  lid  may 
result  in  important  secondary  lesions  of  these  structures.  These 
sequels  are  similar  to  those  resulting  from  mere  irregularity  in  the 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL 


237 


direction  of  the  lashes  or  the  manner  of  their  growth,  Ijiit  are  more 
marked  when  the  lid  itself  is  turned  inward. 

The  sm'geon  who  attempts  to  correct  these  defects  must  be 
familiar  with  plastic  operations  about  the  lids.  In  addition  the 
discomforts  from  inturned  lashes  or  lids  may  require  him  to  modify 
or  add  to  his  operative  plastic  work  about  the  eye,  when  he  seeks  to 
modify  some  more  disfiguring  condition. 


Fig.  262. — Traumatic  loss  of  upper  eyelid. 

weeks. 


Frontal  flap  to  make  new  eyelid. 

{Author'' s  case.) 


Result  after  a  few 


The  treatment  of  illy  grown  lashes  whether,  trichiasis  or  distichi- 
asis,  and  that  of  entropion  may  be  considered  together.  They 
are  often  associated.  In  trichiasis  the  lashes  or  some  of  them  grow 
inward  toward  the  eyeball  and  consequently  rub  it.  In  distichiasis 
there  are  two  rows  of  well  developed  lashes,  one  of  which  turns 
inward. 

In  minor  instances  of  ingrowing  eyelashes  the  hair  bulbs  ma}^  be 
destroyed  by  thrusting  a  fine  platinum  needle  attached  to  the  negative 
pole  of  a  galvanic  battery  into  each  follicle  and  placing  the  wetted 
sponge  of  the  positive  pole  on  the  cheek.  The  passage  of  the  current 
kills  the  hair  and  it  is  easily  pulled  out  and  will  not  be  reproduced. 

In  worse  cases  the  whole  length  of  the  edge  of  the  lid  may  be  split 


238 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


with  a  sharp,  thin  knife  inside  the  line  of  lashes,  a  parallel  incision  be 
made  in  the  skin  of  the  lid  beyond  the  bases  of  the  hairs,  and  a  strip  of 
tissue  including  all  the  follicles  be  dissected  away.  This  if  done  thor- 
oughly scalps  the  edge  of  the  lid  and  no  lashes  can  grow  thereafter. 


.\ 


Fig.  263.- 


-Ectropion  of  upper  eyelid,  after  avulsion  of  entire  scalp,  treated  by  frontal  and  nasal 
flaps.     Skin  grafting  over  cranium.     (Author's  case.) 


The  edges  of  the  trough  left  by  the  incision  may  be  stitched  together 
with  fine  sutures. 

Another  method  is  to  split  the  lid  inside  the  line  of  the  lashes 
and  transplant  into  the  open  wound  a  long  elliptical  strip  of  skin, 


^^^'miiiiimww^^^^ 


Fig.  264. — A  plastic  restoration  of  eyebrow. 


taken  from  behind  the  ear,  or  from  the  skin  of  the  same  lid,  if  it  need 
eversion  as  well  as  an  improvement  in  the  direction  of  its  lashes. 
The  little  strip  of  skin  need  not  be  sutured  into  its  new  position  if  it 
is  pressed  into  the  cut  and  the  eyelids  are  supported  by  a  sterile  com- 
press and  bandage  for  three  or  four  days.     A  strip  of  mucous  mem- 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL 


239 


brane  from  the  inside  of  the  lower  lip  or  a  Thiersch  graft  may  be  used 
instead  of  skin. 

Inversion  of  the  lid  itself  may  be  corrected  by  cutting  away  a 
narrow  horizontal  strip  of  skin  on  its  outside,  just  beyond  the  line 


Fig.  265. — Green's  entropion  operation.      Fig.  266. — Harlan's  entropion  operation. 

of  the  lashes,  and  making  a  horizontal  incision  through  the  conjunc- 
tiva and  tarsal  cartilage  parallel  to  the  lid  margin  about  two  milli- 
meters away  from  the  edge  of  the  lid.  Stitches  of  linen  or  silk  are 
then  introduced  from  the  inside  of  the  lid  below  the  internal  incision, 


-to 


Fig.  267. — Vertical  section  of  the  eyelid,  sm,  bony  supraorbital  margin;  to,  tarso-orbital  fascia; 
Z,  tendon  of  the  levator  muscle;  t,  tarsus;  m,  orbicularis  muscle;  e,  eyelash;  s,  skin;  d,  upper  border 
of  wound;  /,  lower  border  of  wound;  a,  6,  course  followed  by  suture.     {Hotz.) 

carried  through  the  lid  so  as  to  emerge  from  the  lower  part  of  the  cut  in 
the  skin,  introduced  at  the  upper  part  of  that  cut,  carried  subcutane- 
ously  but  deeply,  and  finally  brought  out  through  the  skin  about  a 


240 


SURGERY  OF  DEFORMITIES  OF  THE  FACE 


centimeter  above  the  upper  edge  of  the  skin  wound.  When  these 
stitches  are  tied  the  inverted  lid  is  bent  outward  so  that  its  edge  is 
no  longer  curled  inward.  It  is  necessary  to  have  the  cut  on  the  con- 
junctival surface  go  completely  through  the  tarsal  cartilage.  Other- 
wise the  deformity  will  be  likely  to  recur  from  the  resiliency  of  the 
cartilage. 

Harlan  has  perhaps  improved  on  this  operation  of  Green  by  split- 
ting the  edge  of  the  lid  just  inside  of  the  eyelash  line,  and  making  a 
horizontal  wound  on  the  outside  of  the  lid  which  removes  some  of  the 
orbicular  muscle  as  well  as  the  skin. 


Fig.  268. — Arlt's  operation  for  entropion,  showing  method  of  sphtting  Kd. 


Sutures  are  carried  from  the  conjunctival  surface  out  through  the 
intermarginal  split,  around  the  eyelash  border  into  the  skin  wound, 
through  the  muscle  and  out  through  the  skin  near  the  orbital  attach- 
ment of  the  eyelid.  Such  sutures  when  tied  evert  strongly  the  outer 
portion  of  the  lid  with  the  lashes. 

The  incurved  lid  often  may  be  permanently  everted  by  making  a 
horizontal  incision  through  the  skin  from  canthus  to  canthus,  just 
at  the  site  of  the  orbital  edge  of  the  tarsal  cartilage.  The  lips  of  the 
incision  are  then  separated  by  traction  on  them,  and  sutures  are  so 
placed  that  the  margin  of  skin  nearer  the  edge  of  the  lid  is  fastened  to 
the  orbital  border  of  the  cartilage,  when  the  threads,  which  come  out 
through  the  other  margin  of  the  skin  wound,  are  knotted.  Four  or 
five  sutures  are  placed  in  this  manner. 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL  241 

In  complicated  cases  there  may  be  required  in  addition  to  this 
procedure,  canthoplasty,  and  the  placing  of  a  skin  graft  in  the  margin 
of  the  lid,  as  in  operating  for  the  cure  of  trichiasis. 

Another  operation,  which  may  be  available,  exposes  the  tarsal 
cartilage  from  the  skin  surface  of  the  lid,  and  cuts  out  a  horizontal 
wedge  of  the  cartilage  from  one  canthus  to  the  other.  The  resected 
cartilage  should  then  be  united  by  fine  sutures  so  as  to  convert  the 
inversion  into  eversion. 

The  slight  spasmodic  inversion  of  the  lower  eyelid  of  aged  persons 
may  be  overcome  by  painting  a  little  collodion  on  the  cheek  just 
below  the  lashes.  The  contraction,  occurring  when  the  collodion 
dries,  draws  the  lid  outward.  An  application  every  three  or  four 
days  will  usually  be  sufficient.  Care  must  be  taken  not  to  allow  any 
of  the  collodion  to  get  on  the  mucous  surface,  as  it  will  cause  pain. 
After  a  few  applications  the  spasmodic  entropion  will  sometimes 
cease  to  occur. 

Disfigurements  of  the  Eyeball.     Tumors  of  the  Conjunctiva. 

Tumors  of  the  ocular  conjunctiva,  causing  deformity  or  other 
annoyance,  should  be  snipped  away.  Then  the  wound  should  be  closed 
by  undermining  the  conjunctiva  and  applying  sutures. 

Pterygium,  a  triangular  fleshy  growth  consisting  of  hypertrophied 
mucous  membrane  and  submucous  tissue,  is  a  not  unusual  disfigure- 
ment of  the  eye.  Its  site,  as  a  rule,  is  on  the  inner  portion  of  the  eye- 
ball. Its  apex  is  directed  toward  the  cornea  and  it  may  increase  in 
bulk  and  length  until  its  point  reaches  the  center  of  the  cornea. 
When  it  encroaches  on  the  surface  of  the  cornea  it  interferes  with  vision 
by  reason  of  its  opaque  character. 

If  the  pterygium  is  simply  excised,  it  frequently  recurs  in  the  scar 
of  the  wound  even  when  the  conjunctiva  has  been  used  to  cover  the 
bared  sclerotic  coat. 

One  of  the  best  methods  of  operating  is  to  dissect  or  tear  its  apex 
from  the  cornea,  separate  the  tumor  from  the  sclera,  make  a  conjunc- 
tival incision  along  its  lower  margin  from  the  cornea  out  to  the  canthus, 
undermine  the  conjunctiva  below  the  incision  and  bury  the  pterygium 
in  the  pouch  thus  made.  The  growth  is  drawn  under  the  conjunctiva 
by  means  of  a  mattress  suture  carried  through  its  apex  and  tied  on  the 
outside  of  the  mucous  membrane.  The  raw  surface  of  the  tumor  is 
then  applied  to  the  raw  surface  of  the  sclera;  and  its  upper  surface 
lies  in  contact  with  the  raw  under  surface  of  the  undermined  conjunc- 
tiva. It  is  said  to  be  better  not  to  make  a  second  conjunctival  cut 
along  the  upper  edge  of  the  pterygium. 

i6 


242  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

Deformities  of  the  Cornea. 

When  there  has  occurred  severe  inflammation  and  consequent 
destruction  of  corneal  tissue,  as  a  result  of  injury  or  ulceration,  the 
scar  which  remains  after  the  healing  has  an  opaque  white  structure 
and  is  called  a  leucoma.  This  is  so  different  from  the  normal  trans- 
parent corneal  tissue  that  it  greatly  disfigures  the  patient.  If  there 
has  been  perforation  of  the  cornea  and  prolapse  of  the  iris,  the  iris 
becomes  adherent  to  the  cicatricial  tissue,  which  repairs  the  opening  in 
the  cornea,  and  there  remains  an  adherent  leucoma.  After  the  de- 
struction of  a  large  area  of  the  cornea  from  any  cause,  the  iris,  the 
remains  of  the  cornea  and  the  inflammatory  exudate,  which  are 
welded  into  a  scar,  are  often  too  weak  to  resist  the  pressure  of  the 
humors  within  the  eyeball.  The  intra-ocular  tension,  therefore, 
gradually  stretches  the  cicatricial  wall,  which  has  taken  the  place  of 
the  transparent  and  tough  cornea.  The  front  of  the  blind  or  par- 
tially blind  eyeball  consequently  bulges  and 
protrudes  between  the  eyelids.  It  may  be 
impossible  for  the  patient  to  cover  the  pro- 
truding corneal  protrusion  by  even  the  greatest 
effort  to  close  his  lids.  This  condition  is 
called  staphyloma  of  the  cornea. 

Similar  protrusion  may  follow  injury  to 
the  sclera.  Sometimes  a  corneal  staphyloma 
Fig.  269.-Corneai  staphyloma.  ^^  accompauied  by  similar  stretching  of  the 
sclerotic  coat  adjacent  to  the  cornea. 
These  bulging  masses  between  the  lids  are  very  unsightly  and 
should  be  removed,  when  the  vision  of  the  eye  has  been  entirely  lost. 
In  the  major  degrees  of  staphyloma  the  original  affection  has  long 
before  destroyed  the  utihty  of  the  eye  as  an  organ  of  sight.  After 
still  more  extensive  destruction  of  the  eye  from  traumatic  or  other 
forms  of  inflammation,  the  whole  globe  becomes  atrophied,  and  re- 
mains in  the  socket  as  a  movable  but  shrunken  and  sightless  globe.  If 
such  a  condition  of  the  eye  occurs  in  early  life,  the  bones  surrounding 
the  eye  fail  to  develop  as  fully  as  do  those  on  the  other  side  of  the  face. 
Consequently  the  quarter  of  the  face  in  which  the  blind  and  atrophied 
organ  is  situated  is  considerably  smaller  than  the  corresponding  region 
of  the  other  side.  This  partial  atrophy  is  a  disfigurement  and  should 
be  averted  so  far  as  possible  in  growing  persons  by  replacing  the  atro- 
phied and  useless  organ  by  an  artificial  substitute,  which  by  its  bulk 
may  encourage  the  natural  growth  of  the  skeletal  surroundings  of  the 
eyeball. 


DEFORMITIES  OF  THE  EYELIDS  AND   EYEBALL  243 

The  white  scars  on  the  cornea,  termed  leucoma,  may  be  made 
much  less  disfiguring  by  tattooing  them  black  with  India  ink.  The 
cornea  is  made  anesthetic  with  a  cocaine  solution  of  about  4  per  cent, 
strength,  and  a  smooth  paste  of  India  ink,  prepared  by  rubbing  the 
pigment  in  sterile  water,  is  picked  into  the  white  scar  with  a  number 
of  needles  attached  to  a  handle.  The  needle  punctures  should  be 
made  obliquely  into  the  corneal  scar.  The  eyeball  is  to  be  steadied 
by  the  finger  and  the  paint  may  be  rubbed  upon  the  cornea  with  a 
finger  tip.  It  is  unwise  to  grasp  the  conjunctiva  of  the  eyeball  with 
forceps  to  steady  it,  because  particles  of  the  pigment  may  become  im- 
bedded by  chance  in  the  small  wounds  thus  made.  Several  repeti- 
tions of  the  tattooing  at  not  less  than  two  weeks  intervals  are  usually 
necessary  to  gain  sufficient  color.  The  work  should  be  done  aseptic- 
ally  and  the  eye  be  permitted  to  recover  from  the  irritation  of  one 
operation  before  another  is  done.  The  eye  must  be  thoroughly  cured 
of  the  original  inflammation,  which  caused  the  leucoma,  and  free 
from  irritation  before  the  first  tattooing  is  undertaken.  The  operator 
must  be  versed  in  the  diagnosis  of  eye  diseases  and  the  treatment  of 
complicating  possibilities  before  attempting  even  this  simple  procedure 
upon  the  eye.  After  each  tattooing  the  eye  should  be  atropinized  to 
avert  any  possible  adhesions  due  to  an  unexpected  iritis  or  iridocyclitis. 

It  is  best  in  leucoma  covering  the  center  of  the  cornea  to  tattoo 
a  black  spot  in  the  middle,  to  represent  a  pupil,  and  leave  a  narrow 
circle  of  white  around  this  central  spot.  Beyond  this  white  circle  the 
rest  of  the  leucoma  may  be  colored.  This  plan  gives  the  eye  a  fairly 
natural  appearance. 

Other  colors  have  been  tattooed  into  scars  of  this  kind  in  an  en- 
deavor to  imitate  the  color  of  the  iris.  The  change  of  the  glistening 
white  surface  of  the  leucoma  to  a  more  or  less  black  tint  usually  is 
sufficient  to  lessen  the  noticeable  disfigurement.  The  operation  should 
not  be  done  on  thin  scars. 

Transplantation  of  disks  of  transparent  cornea  from  human  eyes 
or  from  the  eyes  of  lower  animals  has  been  clone.  The  graft  has 
become  necrotic  or  finally  opaque  in  nearly  all,  if  not  all,  cases  reported. 
Future  success  seems,  however,  a  possibility.  A  corneal  trephine  is 
used  to  cut  out  the  leucoma  and  to  punch  the  graft  from  the  eye  of 
the  donor.  After  the  disk-shape  graft  has  been  put  in  place,  it  may 
be  held  in  position  by  suturing  a  fold  or  flap  of  conjunctiva  over  it 
and  the  cornea. 

A  small  partial  corneal  staphyloma  may  be  removed  by  elliptical 
excision;  the  edges  of  the  wound  may  be  brought  together  by  fine 
sutures  or  by  the  pressure  of  a  firm  compress  under  the  dressing.     A 


244  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

convenient  way  to  accomplish  the  excision  is  to  transfix  the  bulging 
part  with  a  cataract  needle  to  steady  it.  The  protuberance  is  then 
removed  by  a  curved  incision,  with  knife  or  scissors,  on  each  side. 
The  crystalline  lens  should  be  extracted  from  the  eye. 

A  total  staphyloma  should  be  amputated.  This  is  done  by  thrust- 
ing from  above  downward  three  or  four  curved  threaded  needles 
through  the  ball,  behind  the  ciliary  region.  The  bulging  mass  is  cut 
away  and  the  lens  removed;  then  the  edges  of  the  scleral  stump  are 
brought  into  contact  by  pulling  the  needles  through  the  tissues  and 
tying  the  sutures. 

Instead  of  using  the  transfixing  needles  a  single  needle  may  be 
thrust  through  the  conjunctiva  behind  the  ciliary  region  in  a  manner 
which  will  carry  a  purse  string  around  the  mass  that  is  to  be  removed. 
This  requires  that  the  needle  make  four  punctures.  After  the  staphy- 
loma has  been  cut  away,  and  the  lens  extracted,  tension  on  the  ends 
of  the  single  suture  will  close  the  gaping  wound  and  keep  the  vitreous 
humor  from  escaping  from  the  cup-like  scleral  stump.  Care  must 
be  observed  not  to  unconsciously  cut  the  buried  purse  string  with  the 
knife  or  scissors  used  to  excise  the  projecting  scar  tissue. 

Some  operators  advocate  enucleation  of  the  eyeball  or  its  eviscera- 
tion with  the  insertion  of  an  artificial  vitreous  body  instead  of  am- 
putation. Their  reason  is  the  fear  of  ophthalmitis  in  the  eye  operated 
upon  or  sympathetic  inflammation  in  the  normal  eye. 

These  complications  are  rare  in  well  performed  aseptic  operations, 
in  which  the  lens  is  evacuated  and  the  staphyloma  removed  by  in- 
cisions behind  the  ciliary  region.  The  movable  stump  thus  left 
after  removal  of  a  total  corneal  staphyloma  forms  a  good  support  for 
an  artificial  glass  shell  eye;  and  the  vitreous  body  enclosed  in  the 
scleral  cup  is  better  than  a  glass,  metal  or  paraffin  substitute  for  the 
vitreous  body. 

There  are  undoubtedly  cases,  however,  in  which  evisceration  of  the 
globe,  with  or  without  the  use  of  an  artificial  vitreous  body,  or  enuclea- 
tion may  be  wiser  than  amputation  of  the  staphylomatous  mass. 

Removal  of  the  eyeball  itself  in  young  subjects  is  much  more 
likely  to  cause  a  want  of  proper  growth  of  the  bones  of  that  side  of  the 
face  than  an  operation,  which  leaves  the  posterior  part  of  the  staphy- 
lomatous eye  in  the  orbit. 

Atrophy  of  the  eyeball  occurring  after  destructive  inflammation 
may  permit  the  wearing  of  an  artificial'eye.  If  the  glass  shell  causes 
pain  or  if  the  blind  organ  is  painful  from  any  cause,  its  enucleation  is 
to  be  recommended.  An  artificial  eye  may  be  then  inserted  and  will 
lessen  the  disfigurement. 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL  245 

In  cases  of  unusual  difference  in  the  size  of  the  eyeballs,  because 
one  eye  is  congenitally  too  small,  some  cosmetic  improvement  may 
be  made  by  lessening  the  palpebral  aperture  of  the  larger  organ  by 
tarsorrhaphy  and  increasing  that  of  the  other  by  a   canthoplasty. 

When,  exophthalmos  remains  after  partial  or  nearly  complete 
recovery  from  Graves's  disease  the  staring  eyes  can  be  greatly  improved 
cosmetically  by  suturing  the  edges  of  the  outer  canthus  and  thus 
diminishing  the  excessive  size  of  the  opening  between  the  lids. 

In  enophthalmos,  due  to  fracture  of  the  orbital  bones  with  sinking 
of  the  eyeball,  the  other  eye  may  be  made  to  correspond  in  size  by 
suturing  the  outer  canthus.  The  noticeable  lack  of  cosmetic  symmetry 
may  be  thus  remedied  easily  and  without  risk. 

It  is  perhaps  possible  that  some  improvement  might  be  made  in 
congenital  absence  of  the  globe  of  the  eye  by  plastic  and  prosthetic 
surgery. 

A  blind  eyeball,  which  is  unsightly  from  staphyloma  or  which 
does  not  permit  a  glass  eye  to  be  worn  over  it,  may  be  removed  entirely 
by  the  operation  called  enucleation.  As  has  been  previously  stated 
staphylomatous  corneas  may  be  made  satisfactory  as  to  comeliness 
by  removing  the  anterior  section  of  the  ball  and  adjusting  a  glass 
shell  to  the  stump.  Instead  of  entirely  removing  the  eyeball,  by 
cutting  its  muscles,  the  optic  nerve  and  the  connective  tissue  about 
it,  the  operation  of  evisceration  may  be  performed. 

This  procedure  removes  the  anterior  part  of  the  eye,  as  in  ampu- 
tation of  a  staphylomatous  cornea,  but  in  addition  scoops  or  wipes 
out  of  the  containing  sclera  the  iris,  ciliary  body,  choroid,  retina  and 
vessels,  leaving  a  perfectly  clean  and  aseptic  sclerotic  cup.  As  this 
posterior  scleral  section  has  the  extrinsic  muscles  of  the  globe  attached 
to  it  and  partially  fills  the  cavity  of  the  orbit,  the  artificial  eye  worn 
over  it  fills  out  the  space  under  the  eyelids  quite  well  and  has  a  great  deal 
of  mobility.  The  cosmetic  gain  is  therefore  great  compared  with  that 
obtained  when  using  a  glass  shell  after  an  enucleation.  Then  the 
stump  is  too  small  to  fill  up  the  cavity  formerly  occupied  by  the  eye- 
ball and  the  upper  eyelid  drops  back  into  the  orbit.  This  causes  an 
unnatural  hollow  under  the  eyebrow. 

A  still  better  stump  for  the  adaptation  of  an  artificial  eye  shell  is 
secured  by  introducing  into  the  eviscerated  sclerotic  a  ball  of  gold, 
glass  or  paraffin,  which  being  aseptic  remains  enclosed  within  the 
sclerotic  of  the  eye  for  years  without  causing  disturbance.  The  stump 
thus  distended  makes,  when  covered  with  a  glass  shell,  an  almost 
perfect  companion  for  the  normal  eye  of  the  other  side.  The  arti- 
ficial vitreous  body  within  the  scleral  cup  makes  a  mass  nearly  the 


246  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

size  of  the  normal  eyeball.  The  glass  shell  over  it  is  made  to  represent 
the  normal  pupil,  iris,  and  conjunctiva  in  size,  color  and  shape  and  the 
muscles  which  were  left  attached  to  the  sclerotic  give  the  artificial  eye 
motion,  which  coordinates  with  those  of  its  companion  eye. 

Evisceration  with  introduction  of  the  artificial  vitreous  body 
called  Mules's  operation,  is  a  marked  improvement  cosmetically  over 
enucleation. 

A  glass  or  gold  globe  to  constitute  an  artificial  eyeball  is  sometimes 
introduced  with  success  into  the  capsule  of  Tenon  after  enucleation 
has  been  done.  This  is  an  improvement  over  enucleation  of  the  ball 
without  the  use  of  the  gold  or  glass  substitute,  but  does  not  give  so 
good  a  cosmetic  result  as  evisceration  with  the  artificial  vitreous 
body. 

In  these  operations,  all  of  which  require  general  anesthesia,  the 
eyelids  are  kept  widely  apart  with  an  eye  speculum.  Enucleation  is 
done  by  making  with  scissors  a  circular  division  of  the  conjunctiva 
around  the  cornea.  The  rectus  muscles  are  then  successively  raised 
with  a  strabismus  hook  and  cut  off  close  to  the  ball,  leaving,  however, 
at  one  place  a  sufficient  stump  attached  to  the  globe  to  give  oppor- 
tunity for  the  surgeon  to  hold  and  manipulate  the  eyeball  with  a 
pair  of  toothed  forceps.  The  optic  nerve  is  cut  off  at  the  apex  of 
the  orbit  by  slipping  a  pair  of  round  end  scissors  curved  on  the  flat 
into  the  orbit  between  the  ball  and  the  conjunctiva.  The  scissors 
should  be  kept  close  to  the  eyeball,  as  they  are  pushed  backward, 
and  not  opened  until  they  reach  the  nerve.  It  is  best  to  introduce 
them  at  the  external  side  of  the  globe.  After  the  nerve  has  been 
cut,  the  connective  tissue  and  oblique  muscles  still  attached  to  the 
eyeball  are  divided.  Then  the  liberated  globe  is  lifted  out  through 
the  circular  wound  in  the  conjunctiva  by  means  of  the  forceps,  which 
have  been  holding  on  to  the  ocular  stump  of  the  first  rectus  muscle 
divided.  The  four  rectus  tendons  are  now  drawn  forward  and  sewed 
to  the  edge  of  the  conjunctival  wound.  Then  the  capsule  of  Tenon 
and  the  conjunctiva  are  closed  by  sutures,  which  unite  the  edges  of 
the  opening  in  these  tissues  so  as  to  leave  a  horizontal  wound.  A 
compress  and  bandage  are  applied. 

In  order  to  fill  out  the  orbit  and  prevent  collapse  of  the  upper 
eyelid,  a  hollow  sphere  of  gold,  or  glass,  may  be  implanted  in  the 
cavity  left  within  Tenon's  capsule  by  the  removal  of  the  eyeball. 
The  operation  must  be  done  aseptically  and  the  artificial  eyeball 
must  be  aseptic.  After  the  eyeball  has  been  enucleated  as  already 
described  the  space  within  the  capsule  is  packed  for  a  few  minutes 
with  a  ball  of  sterile  gauze  until  bleeding  ceases.     Then  the  hollow 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL  247 

sphere  is  dropped  into  the  cavity  vacated  by  the  enucleated  organ 
and  the  capsule  and  conjunctiva  sutured  over  it.  The  balls  so 
introduced  vary  in  size  from  ten  to  fourteen  millimeters  in  diameter. 

If  the  enucleation  has  been  done  some  time  previously,  the  orbital 
tissues  are  opened  by  a  sufficient  incision,  at  the  upper  lateral  part 
of  the  tissues,  a  pocket  is  made  by  dissection  with  scissors  and  the 
sphere  of  gold  or  glass  is  inserted.     Sutures  are  used  to  close  the  wound. 

The  operation  of  evisceration  is  begun  by  dissecting  the  conjunc- 
tiva from  the  anterior  part  of  the  globe  of  the  eye  through  a  circum- 
corneal  incision.  After  exposing  the  globe  as  far  back  as  its  equator, 
the  cornea  and  a  little  of  the  adjacent  sclera  is  cut  away  with  knife 
and  scissors.  Then  all  the  contents  of  the  sclerotic  coat  are  scooped 
out  with  a  small  spoon.  If  these  are  not  completely  removed  with  the 
spoon,  the  cavity  must  be  cleared  of  fragments  by  mopping  with 
cotton  or  gauze  tufts  held  in  forceps.  The  scleral  cup  may  require 
firm  packing  with  gauze  for  a  few  moments  to  stop  bleeding.  The 
circular  opening  in  the  sclera  should  be  converted  into  a  more  ellip- 
tical form  by  removing  small  triangular  pieces  above  and  below,  to 
render  accurate  closure  possible.  Sutures  are  then  used  through  the 
conjunctiva  and  sclera  to  draw  the  wound  edges  together.  A  compress 
and  gauze  dressing  complete  the  procedure. 

Into  the  eviscerated  sclera  a  hollow  sphere  of  glass  or  gold  or  a 
solid  sphere  of  paraffin  may  be  implanted.  Before  the  artificial 
vitreous  body  has  been  inserted  all  particles  of  choroid  and  other 
contents  must  be  carefully  and  aseptically  removed.  The  interior 
of  the  sclera  must  be  white  and  glistening.  The  sphere  of  not  too 
tight  a  fit  is  then  dropped  into  the  scleral  cup  and  the  scleral  wound 
closed  vertically  with  a  few  interrupted  linen  or  silk  sutures.  The 
conjunctiva  is  sutured  so  that  the  wound  is  horizontal.  A  compress 
and  a  bandage  are  applied  and  the  dressing  may  usually  remain  un- 
changed for  two  days.     This  operation  was  devised  by  Mules. 

Dr.  L.  Webster  Fox  prefers  to  cut  the  rectus  muscles  free  from  the 
globe  of  the  eye  after  the  ball  has  been  inserted  and  the  sclerotic 
coat  stitched.  Then,  when  he  closes  the  conjunctiva,  he  is  careful 
to  include  in  his  sutures  the  capsule  of  Tenon.  This  replaces  the  ends 
of  the  rectus  muscle  close  to  the  eyeball  again  and  they  become  at- 
tached to  it.  This  method,  he  believes  prevents  muscular  strain  on 
the  scleral  sutures  during  the  earl}-  healing  of  the  opening  in  that 
coat.  Therefore  there  is  less  danger  of  the  artificial  vitreous  body 
being  expelled  through  an  imperfectly  healed  scleral  wound.  By 
drawing  Tenon's  capsule  forward  by  means  of  the  conjunctival  sutures 
the  reattachment  of  the  muscles  to  the  eveball  is  attained.     Conse- 


248  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

quently  the  movements  of  the  stump  and  the  adjusted  glass  prosthesis 
are  secured. 

He  also  places  over  the  conjunctival  surface  a  glass  or  metal  '^con- 
former"  which  lying  under  the  closed  eyelids  steadies  the  scleral 
stump  like  a  splint.  Sterile  petrolatum  is  smeared  over  the  closed 
lids.  Moderate  pressure  with  the  bandage  or  compress  is  to  be  main- 
tained for  about  forty-eight  hours.  Dr.  Fox  removes  the  "  conformer  " 
and  the  conjunctival  sutures  on  the  third  or  fourth  day. 

The  extirpation  of  the  contents  of  the  orbital  cavity  in  addition 
to  removal  of  the  eye  is  sometimes  important,  because  of  the  existence 
of  malignant  disease  of  the  eyeball  and  its  surroundings.  This  opera- 
tion is  called  exenteration  of  the  orbit.  It  is  performed  by  opening 
with  a  knife  the  tissues  within  the  orbit,  near  the  border  of  the  orbit. 
The  lids  must  be  held  open  with  a  speculum  for  the  operation  and  the 
external  canthus  may  be  split.  The  periosteum  just  within  the  or- 
bital edge  is  then  split  with  the  knife.  This  permits  the  operator  to 
detach  the  periosteum  from  the  inner  surface  of  the  wall  of  the  orbital 
cavity  all  the  way  back  to  its  apex.  Care  must  be  taken  not  to  per- 
forate the  thin  roof,  lest  intracranial  complications  occur.  The  entire 
contents  of  the  orbit  are  then  removed  by  dividing  the  posterior 
attachments  with  scissors.  It  makes  the  operation  somewhat  easier 
to  enucleate  the  globe  of  the  eye  before  detaching  the  periosteum 
and  extracting  all  the  orbital  contents.  This  may  not  be  convenient 
if  the  eyeball  is  greatly  involved  or  partly  destroyed  by  the  malignant 
growth.  After  exenteration  the  cavity  may  be  lined  with  skin 
grafts  or  Thiersch's  skin  shavings.  Kronlein's  temporary  resection  of 
the  outer  wall  of  the  orbit,  to  get  access  to  tumors  in  the  orbit  not 
manageable  by  less  extensive  operations,  will  be  described  when  I 
discuss  deformities  from  orbital  growths. 

The  Use  of  Artificial  Eyes. 

After  total  or  partial  removal  of  the  eyeball  or  its  substitution  by 
globes  placed  in  the  capsule  of  Tenon  or  in  a  scleral  cup,  it  is  usual  to 
adjust  to  the  stump  a  glass  representation  of  the  cornea,  iris,  sclera 
and  conjunctiva.  The  glass  shell  usually  employed  for  this  purpose 
may  be  applied  over  an  atrophied  eyeball,  but  such  practice,  as  a  rule, 
is  not  a  wise  one.  It  is  better  to  get  rid  of  the  atrophied  ball  totally 
or  in  part  and  then  resort  to  the  glass  prosthesis. 

The  use  of  an  artificial  eye  is  valuable  not  only  for  improving  the 
appearance  of  the  patient,  but  also  for  preventing  the  entropion  and 
the  falling  in  of  the  eyelids,  which  are  apt  to  occur  when  the  support 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL  249 

normally  exerted  by  the  eyeball  is  lost.  The  rubbing  of  the  lashes 
against  the  conjunctiva  is  often  painful  and  may  give  rise  to  a  muco- 
purulent discharge,  which  will  excoriate  the  skin  of  the  cheek. 
These  pathological  and  cosmetic  disadvantages  may  be  overcome  to  a 
great  extent  by  wearing  a  glass  e3^e  over  the  stump  left  after  enucleation 
or  evisceration.  An  additional  benefit  is  that  atrophy  of  the  face 
in  the  ocular  region,  common  in  growing  children,  who  have  lost  an 
eye,  is  to  a  considerable  extent  prevented. 

The  glass  or  enameled  shell  represents  the  front  of  the  eyeball  and 
is  made  to  match  the  color  and  size  of  the  iris,  cornea,  sclerotic  and 
conjunctiva  of  the  other  eye.  It  is 
slipped  under  the  upper  lid  and  rests 
with  its  lower  edge  in  the  conjunctival 
groove  within  the  lower  lid.  The  mus- 
cles formerly  inserted  into  the  sclera  of 

,,  ,,  „,,  I'll  1  Fig.  270. — Artificial  eyes  (glass  shells). 

the  globe  of  the  eye,  which  have  been 

preserved  and  attached  to  the  stump,  give  it  and  the  overlying 
shell  a  considerable  degree  of  concomitant  movement  with  the 
other  eye.  If  the  lateral  movements  of  the  organ  are  fairly  good, 
the  eyelids  able  to  close  over  the  artificial  eye,  and  the  color  and 
size  of  the  substitute  the  same  as  those  of  the  normal  eye,  the  casual 
observer  may  not  detect  that  one  eye  is  a  sham.  The  sinking  in  of 
the  fold  of  skin  above  the  upper  lid,  due  to  the  loss  of  ocular  support, 
may  be  prevented,  the  normal  position  of  the  upper  and  lower  eyelashes 
be  obtained,  and  winking  and  the  coordinate  movements  of  both  eyes 
be  satisfactory,  if  a  partially  shrunken  ball  remains  or  the  bulk  of 
the  stump  has  been  increased  by  a  sphere  of  glass  or  other  material. 
Unless  the  surgeon  has  been  successful  in  meeting  these  requirements, 
the  patient  may  be  more  comfortable  and  less  disfigured  by  allowing 
the  lids  to  rest  closed  upon  the  vacant  orbit  than  by  wearing  a  badly 
fitted  and  badly  matched  glass  eye.  The  shell  is  not  well  tolerated 
as  a  rule  by  a  stump  in  which  there  remains  any  normal  cornea. 

The  glass  eye  must  be  smooth  on  the  surface  and  have  no  sharp 
edges.  Its  shape  must  correspond  to  a  certain  extent  with  the  cic- 
atricial requirements  of  the  conjunctival  pouch  in  which  it  is  to  be 
worn.  An  eye  a  little  too  small  may  be  worn  with  much  comfort, 
but  one  too  large  is  a  source  of  discomfort  and  disfigurement.  The 
former  may  have  its  cosmetic  effect  enhanced  by  wearing  in  front  of 
it  a  convex  lens  to  give  it  the  apparent  size  of  its  larger  fellow.  The 
latter  should  have  in  the  spectacle  frame  a  plain  glass  or  that  which 
will  correct  any  existing  refractive  error.  A  furrow  above  the  upper 
eyelid  of  an  eye,  from  wdiich  the  globe  has  been  enucleated,  may  be 


250  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

concealed  by  wearing  a  spectacle  or  eyeglass  frame  made  wider  than 
is  usual. 

When  the  glass  shell  loses  its  smooth  surface  or  gets  sharp  on  the 
edges,  it  must  be  rejected  or  have  its  surface  and  edges  repolished. 
Otherwise  it  will  cause  conjunctivitis  and  perhaps  ulceration  and  con- 
traction of  the  conjunctiva.  These  sequels  may  render  the  use  of  a 
substitute  eye  impossible.  A  good  shell  will  last  from  one  to  three 
years.  The  time  varies  with  the  character  of  the  secretions  of  the 
eye  and  the  quality  and  material  of  the  artificial  eye.  The  patient 
should  take  out  the  eye  when  going  to  bed  at  night  and  replace  it  in 
the  morning.  It  should  be  thoroughly  washed  with  a  mild  antiseptic 
or  an  aseptic  solution  and  dried.  When  it  is  to  be  inserted  in  the 
morning,  it  should  be  moistened  and  replaced  with  clean  fingers.  The 
cavity  under  the  eyelids  should  be  kept  aseptic  by  washing  morning 
and  evening  with  a  solution  of  boric  acid  of  about  five  grains  to  the 
fluid  ounce  of  water. 

After  removal  of  the  globe  by  one  of  the  methods  already  described 
an  artificial  eye  may  be  inserted  as  soon  as  inflammation  has  subsided. 
This  may  be  after  the  lapse  of  say  three  weeks  in  the  usual  case.  At 
first  it  may  be  worn  for  a  few  hours  only,  but  if  the  patient  finds  it 
uncomfortable,  its  use  should  be  postponed  for  further  subsidence  of 
the  post-operative  irritation.  It  is  not  well  to  wait  a  very  long  time, 
because  conjunctival  and  palpebral  contraction  may  occur. 

To  introduce  a  glass  shell  the  patient  should  be  looking  upward. 
The  upper  lid  is  then  drawn  forward  by  the  finger  of  the  surgeon,  or  of 
the  patient  himself,  making  traction  on  the  skin  below  the  eyebrow. 
Then  that  edge  of  the  shell  which  has  most  sclerotic  represented  is 
slipped  under  the  upper  lid.  The  lower  lid  is  next  drawn  down  a 
little  by  traction  on  the  skin  below  it,  so  that  the  lower  edge  of  the 
shell  may  slip  over  it  and  drop  into  the  lower  conjunctival  groove. 
The  patient  then  is  allowed  to  wink  and  the  shell  assumes  the  proper 
position.  It  may  require  the  insertion  of  several  glass  eyes  before  one 
is  found  which  is  comfortable  and  a  good  match  as  to  size,  color  and 
movement.  To  remove  the  artificial  eye  the  patient  should  look  up- 
ward and  insert  the  head  of  a  large  pin  or  any  similar  blunt  instrument 
beneath  its  lower  border  so  as  to  tilt  it  out  over  the  edge  of  the  lower 
lid.  This  is  soon  learned  and  may  be  done  quickly  by  simply  everting 
the  lower  lid  with  the  finger  and  moving  the  stump  on  which  the  shell 
rests.  Until  the  patient  becomes  dextrous  in  introducing  and  re- 
moving the  shell  he  should  lean  over  a  bed,  lest  the  glass  eye  be 
dropped  on  the  floor  and  broken. 

Instead  of  the  shell  a  thicker  eye  of  glass,  with  or  without  a  central 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL  251 

cavity,  and  with  less  sharp  edges,  has  been  found  satisfactory  by  some 
ophthalmic  operators.  Its  under  surface  does  not  leave  a  deep  hollow 
for  the  collection  of  secretions  as  does  the  shell  of  glass. 

Other  forms  have  been  manufactured  for  special  cases,  as  in  eyes 
with  very  deep  or  irregularly  cicatrized  sockets.  The  latter  may 
have  a  long  tongue  of  glass  on  one  edge  to  hold  the  shell  in  place. 

When  a  socket  has  become  contracted  or  cicatricial,  it  may  be  too 
small  to  admit  an  artificial  eye.  Attempts  to  enlarge  the  socket  may 
be  made  by  splitting  the  tissues  freely  horizontally  and  perhaps 
vertically  and  inserting  a  free  flap  of  mucous  membrane  taken  from 
the  inside  of  the  lower  lip.     This  may  be  stitched  in  place  or  simply 


Fig.  271. — Artificial  eye,  double  Fig.  272. — Hollow  artificial  eye 

wall  shell.  for  a  deep  socket. 

laid  in  contact  with  the  raw  surface.  Thick  Thiersch  skin-grafts  or 
skin-grafts  taken  from  behind  the  ear  or  elsewhere  can  be  similarly 
applied.  A  ball  of  gauze  or  glass  or  some  form  of  plate  or  conformer 
may  be  inserted  under  the  lids  to  hold  the  graft  in  position  before  the 
lids  are  closed  and  dressed  with  an  aseptic  compress.  It  may  perhaps 
be  better  to  split  the  outer  canthus  and  turn  into  the  orbital  cavity  a 
pediculated  flap  from  the  temple.  When  this  flap  has  become  attached 
to  the  bottom  of  the  socket  the  pedicle  may  be  divided  and  the  canthus 
closed. 

Deformities  from  Orbital  Growths. 

Growths  in  the  orbit  produce  facial  disfigurement  by  displacing 
the  eyeball,  preventing  proper  closure  of  the  lids,  and  bj'  causing 
bulging  of  the  bones,  which  constitute  the  walls  of  the  orbit.  The 
effects  of  such  tumors  on  the  vision  and  their  menace  to  the  general 
health  or  life  of  the  patient  are  topics  not  connected  with  the  present 
discussion. 

Tumors  found  in  the  orbit  may  cause  exophthalmos,  or  protrusion 
of  the  entire  ball,  as  occurs  when  they  are  situated  within  the  muscular 
funnel,  or  deviations,  usually  to  the  side  away  from  the  tumor,  if  they 
are  outside  of  the  muscles.     They  often  cause  double  vision.     They 


252  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

may  be  benign  or  malignant,  and  solid,  cystic  or  vascular,  as  are 
tumors  in  other  regions. 

Exophthalmic  goiter,  aneurism  of  the  ophthalmic  or  internal 
carotid  artery,  and  arterio-venous  fistule  between  the  internal  carotid 
artery  and  the  cavernous  sinus  cause  ocular  displacement  and  conse- 
quent disfigurement.  They  must,  however,  be  recognized  as  patho- 
logical conditions  in  which  the  disfigurement  is  of  less  importance  than 
the  other  symptoms.  Mucous  retention  and  abscesses  associated  with 
disease  of  the  frontal  or  ethmoid  sinuses  also  encroach  upon  the  orbit 
and  must  be  remembered.  Tumors  in  the  orbit  may  arise  from  the 
globe,  from  the  periosteum  or  bone,  from  the  optic  nerve,  and  from 
the  other  structures  between  the  eyeball  and  the  walls  of  the  orbital 
cavity. 

Some  orbital  growths  are  removable  without  sacrificing  the  eye 
itself,  others  require  exenteration,  or  total  extirpation  of  all  tissues 
within  the  orbit,  while  others  are  reached  only  after  a  temporary 
resection  of  a  part  of  the  orbital  wall. 

Non-malignant  tumors  of  the  orbit  outside  of  the  muscles  of  the 
eyeball  may  be  removed  without  damaging  the  eyeball.  A  cut  is 
made  at  the  bony  margin  of  the  orbit  and  the  orbital  fat  and  the 
eyeball  with  its  attached  muscles  are  displaced  so  that  the  tumor 
may  be  enucleated.  The  growth  is  then  removed  and  the  globe  of  the 
eye  permitted  to  fall  into  its  place.  Drainage  may  or  may  not  be 
necessary.  The  external  side  of  the  orbit  perhaps  gives  better  access 
to  the  orbital  cavity  than  other  regions;  but  the  site  of  the  tumor 
must  be  a  guide  to  the  route.  If  necessary  the  external  canthus  of 
the  eye  may  be  split,  to  afford  room  for  extirpating  the  tumor.  At 
times  it  may  be  necessary  to  divide  the  tendon  of  the  external  rectus 
muscle  temporarily.  In  such  cases  the  ends  of  the  tendon  should  be 
secured  by  sutures,  whch  may  be  used  to  unite  the  tendon  when 
the  operation  wound  is  being  closed.  Cystic  tumors  are  usually  better 
managed  by  enucleation  than  by  incision  and  drainage.  Mucoceles, 
communicating  with  the  accessory  sinuses  of  the  nose,  involving  the 
palpebral  or  orbital  tissues  are  an  exception  to  this  statement. 

When  the  deformity  is  caused  by  malignant  tumors  involving  the 
eyeball  and  orbital  tissues,  exenteration  of  the  orbit  as  previously 
described  is  the  operation  to  be  performed.  At  times  they  cannot  be 
extirpated  well  unless  abundant  room  is  given  for  the  operator's  work. 
Then  temporary  resection  of  the  external  orbital  wall  as  devised  by 
Kroenlein,  or  some  similar  method,  is  to  be  adopted. 

In  this  operation  a  curved  incision,  through  the  skin  and  fascia 
down  to  the  bone  is  made  over  the  outer  part  of  the  orbital  border  with 


DEFORMITIES  OF  THE  EYELIDS  AND   EYEBALL 


253 


its  convexity  toward  the  eye.  The  ends  of  this  cut  run  up  on  the 
temple  and  outward  along  the  upper  edge  of  the  zygoma.  Next  the 
periosteum  lining  the  outer  orbital  wall  is  incised  and  detached  along 
the  exposed  edge.  It  is  then  loosened  from  the  wall  and  pushed  to- 
ward the  eye,  until  the  front  end  of  the  spheno-maxillary  fissure  in 
the  outer  and  lower  part  of  the  orbital  wall  is  uncovered.  This  is 
marked  by  putting  the  end  of  a  probe  into  it.  A  small  sharp  osteo- 
tome is  then  used  to  cut  out  a  wedge-shape  piece  of  the  bony  outer  wall 
of  the  orbit.  The  lines  along  which  this  bony  segment  is  cut  run  from 
the  anterior  end  of  the  fissure  mentioned.     One  line  runs  upward  and 


s — r^ 


Fig.  273. — Kroenlein's  operation  of  temporary  resection  of  outer  wall  of  orbit  to  remove  orbital 

growths.      (Knapp.) 


outward,  passing  through  the  margin  of  the  orbit  at  a  point  near  the 
junction  of  the  external  angular  process  of  the  frontal  bone  and  the 
malar  bone.  The  other  runs  outward  and  a  little  upward,  dividing 
the  ascending  process  of  the  malar  bone  near  its  base.  If  a  chisel  is 
used  it  should  be  driven  from  the  exterior  of  the  orbital  margin  in  the 
lines  mentioned  to  the  end  of  the  fissure,  in  which  a  probe  has  been 
already  thrust  for  a  marker.  A  small  nasal  saw  could  probably  be 
used  as  well.  The  wedge  of  bone  thus  detached  should  measure  about 
one  and  a  half  inches  vertically  and  run  about  two  inches  in  length  into 
the  orbit.  Splitting  the  periosteum,  which  has  been  detached  before 
the  osteoplastic  resection  is  made,  and  then  turning  the  ])ony  wedge 


254  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

and  the  soft  parts  attached  to  it  outward  and  backward,  enable  the 
operator  to  expose  the  deep  parts  of  the  orbit,  and  extirpation  of  tumor 
therein  can  be  effectually  performed. 

After  removal  of  the  growth  the  periosteum  is  sutured,  the  wedge 
of  bone  bent  into  place  and  the  overlying  soft  tissues  are  sutured. 

Parinaud  and  Roche  have  modified  the  method  of  Kroenlein.^ 

Strabismus. 

If  the  visual  axis  of  one  eye  only  is  directed  toward  an  object, 
at  which  the  patient  looks  and  the  other  eye  deviates,  strabismus, 
or  squint,  exists.  When  the  lack  of  muscular  control  is  due  to  a 
weakness,  or  insufhcienc}^,  of  muscle,  the  patient  may  overcome  the 
resulting  double  vision  by  an  increased  contraction  of  the  necessary 
muscle.  This  may  cause  pain  from  the  strain  on  the  nervous  system, 
but  does  not  give  rise  to  ocular  disfigurement. 

Deformity  occurs  when  this  cannot  be  done  and  one  of  the  eyes 
always  has  the  axis  inverted,  diverted,  or  vertically  out  of  coor- 
dination with  its  fellow.  The  strabismus  may  be  due  to  paresis  or 
paralysis  of  one  or  more  of  the  extrinsic  muscles  of  the  eye,  or  to  mus- 
cular spasm.  The  latter  condition  is  rare,  the  other  is  quite  common. 
Paralytic  squint  shows  an  actual  restriction  of  mobility  when  the 
weakened  or  powerless  muscle  is  called  upon  to  do  its  work;  and  it  is 
by  that  fact  usually  readily  distinguished  from  the  other  forms  of 
strabismus. 

When  the  deviation  depends  upon  improper  coordination  of  the  mo- 
tions of  the  two  eyes,  so  that  they  always  have  the  same  abnormal  re- 
lation of  their  visual  axes,  the  condition  is  one  of  comitant  strabismus. 

The  commonest  form  of  strabismus  is  that  in  which  the  axes  of  the 
two  eyes  converge.  Only  one  eye  fixes  the  object,  at  which  the  patient 
looks.  The  other  eye  looks  inward  toward  the  nose.  If  the  fixing 
eye  is  not  always  the  same,  the  strabismus  is  termed  alternating.  In 
such  instances  the  vision  of  the  two  eyes  is  probably  equally  good. 

Monocular  comitant  squint  is  the  term  employed  when  the  same 
eye  always  fixes  and  the  other  always  deviates.  Then  the  deviating  eye 
usually  is  found  to  have  less  visual  acuity  than  the  fixing  eye.  This 
form  of  squint  is  very  apt  to  be  associated  with,  and  in  fact  to  be  caused 
by,  hyperopic  refraction,  which  necessitates  an  abnormal  exercise 
of  the  accommodation.  It  is  first  noticed  as  a  rule  at  about  the  age 
four  years,  when  children  begin  to  use  their  eyes  in  looking  at  near 
objects,  such  as  books  and  toys. 

^  See  Ball's  "Modern  Ophthalmology,"  p.  653. 


DEFORMITIES  OF   THE   EYELIDS  AND  EYEBALL  255 

External  strabismus  is  the  form  of  lateral  strabismus,  in  which  the 
deviating  eye  is  constantly  turned  outward.  It  is  apt  to  be  associated 
with  myopia,  though  it  may  be  due  to  blindness  in  the  deviating  eye 
or  to  previous  oculo-motor  paralysis.  It  is  more  apt  to  appear  later 
in  life  than  childhood. 

Vertical  scjuint,  or  strabismus,  is  uncommon  and  is  apt  to  be 
paralytic  if  it  is  sufficient  to  cause  disfigurement  of  the  expression  of 
the  face. 

Xo  surgeon  should  attempt  to  correct  the  deformity  clue  to  a 
strabismic  eye,  unless  he  is  familar  with  the  optical  problems  involved 
in  its  causation  and  treatment.  Paralytic  sc{uint  may  be  due  to  af- 
fections of  the  muscles,  the  nerve  trunks  or  the  nerve  centers  in  the 
brain.  The  treatment  therefore  depends  not  only  on  the  character  of 
the  cause,  but  on  its  location.  Muscular  lesions  may  be  wounds,  scar 
contractions,  or  pressure  from  new  growths.  The  nerves  may  be- 
come paralyzed  by  pressure  from  hemorrhage,  or  from  swelling  of  the 
nerve  sheath  or  of  the  adjacent  tissues.  They  may  be  the  seat  of 
degenerations  and  inflammations,  or  have  their  function  impaired  by 
toxic  influences.  The  cerebral  nuclei  are  subject  to  similar  disturbing 
agencies.  Nephritis,  cardiovascular  disease,  alcoholism  and  acute 
general  infections  may  give  rise  to  paralytic  sciuint.  The  medicinal 
treatment  must  be  based  on  the  etiology.  It  is  a  clinical  fact  that 
many  external  ophthalmoplegias  are  cured  by  full  and  prompt  anti- 
syphilitic  treatment.  Operative  treatment  should  not  be  undertaken 
in  paralytic  strabismus  until  medicines,  electricity,  orthopedic  training 
with  prisms,  and  hygienic  measures  have  been  given  a  fair  and  there- 
fore a  rather  lengthy  trial. 

Comitant  convergent  sc^uint  of  young  children  should  be  managed 
by  constantly  wearing  lenses  correcting  the  refractive  error.  If 
this  is  done  early,  cure  will  often  result  without  operation.  This  is 
the  case  because  so  many  instances  are  the  result  of  hyperopia  neces- 
sitating abnormal  accommodative  effort  on  the  part  of  the  child. 

In  cases  where  cure  of  the  deforming  squint  does  not  follow  the 
correction  of  the  refractive  error  and  the  constant  use  of  the  lenses, 
tenotomy  of  the  internal  rectus  muscle  in  one  or  both  eyes  or  advance- 
ment of  the  tendon  of  one  or  both  external  rectus  muscles  has  to  be 
done.  Which  of  these  operations  is  preferable  and  whether  the  change 
in  the  axes  of  the  eyes  is  to  be  obtained  by  operating  on  one  or  both 
eyes  has  to  be  determined  by  careful  ophthalmological  study.  It 
must  be  remembered  that  the  convergent  sciuint  is  an  affection  in 
which  both  eyes  are  concerned.     In  severe  cases  it  may  be  necessary 


256  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

to  cut  the  tendons  in  the  internal  rectus  muscles  of  both  eyes  and 
also  to  advance  the  tendons  of  both  external  rectus  muscles. 

The  correcting  lenses  should  be  worn  after  the  operative  correc- 
tion of  the  squint,  to  give  good  vision  and  prevent  return  of  the  de- 
formity. 

In  divergent  strabismus  associated  with  myopia  the  use  of  proper 
correcting  glasses  may  cure  the  deformity.  It  is  important  to  bring 
up  the  vision  to  the  same  acuity  in  both  eyes,  if  this  is  possible.  In 
divergent  cases  the  external  rectus  may  be  divided  or  the  internal 
rectus  tendon  advanced,  or  both  these  operations  may  be  required 
to  obtain  a  proper  relation  of  the  visual  axes. 

There  are  educative  ways  of  training  children  to  use  both  eyes  and 
to  develop  a  proper  relation  of  the  axes  of  the  eyes,  which  are  not 
within  the  scope  of  this  treatise  on  deformities.  These  are  often  also 
of  value  in  preventing  impairment  of  vision  in  the  deviating  eye  due 
to  suppression  of  its  retinal  image.  This  suppression  results  from 
a  cerebral  attempt  to  get  rid  of  the  diplopia,  when  fusion  of  the  two 
ocular  images  is  impossible  on  account  of  the  squint. 

If  binocular  vision  is  possible  after  a  well  chosen  strabismus  opera- 
tion, the  cosmetic  improvement  is  great  and  permanent.  The  proper 
lenses,  to  correct  any  error  in  refraction,  should  be  worn  constantly. 
Sometimes  more  than  one  operation  is  required,  because  it  may  be 
difficult  to  determine  at  the  first  operation  how  much  change  will  be 
produced  by  the  tenotomy  or  other  procedure  adopted. 

These  operations,  except  in  young  children,  are  readily  done 
under  local  anesthesia  by  cocaine.  General  anesthesia  is  unsatisfactory, 
because  the  operator  cannot  see  the  exact  result  of  his  operation  on  the 
muscles  until  after  the  patient  has  regained  consciousness.  When 
convergent  squint  is  treated  by  operative  methods,  it  is  wise  to  leave 
it  a  little  under-corrected;  but  when  divergent  squint  is  thus  treated 
a  slight  over-correction  of  the  deviation  is  wise.  Children  should 
probably  not  be  subjected  to  operation  until  from  five  to  six  years  of 
age.  This  question  must  be  determined  by  a  competent  ophthal- 
mologist and  the  refractive  and  other  methods  of  preserving  vision 
in  the  deviating  eye  should  be  insisted  upon,  if  for  any  reason  opera- 
tion is  postponed. 

The  muscle,  which  pulls  the  eye  in  the  wrong  direction,  may  be 
subjected  to  tenotomy  and  its  ends  allowed  to  retract;  or  the  muscle, 
which  seems  to  be  unable  to  overcome  this  pull,  may  be  shortened  by 
cutting  out  a  piece  and  suturing  the  ends,  or  its  tendon  may  be  ad- 
vanced by  being  detached  from  the  sclerotic  coat  and  stitched  to  that 
structure  nearer  the  corneal  marain.     This  means  that  in  internal,  or 


DEFORMITIES  OF  THE  EYELIDS  AND  EYEBALL  257 

convergent,  squint  tenotomy  of  the  internal  rectus  is  available,  or 
instead  of  that  operation,  shortening  or  advancement  of  the  tendon  of 
the  external  rectus.  In  external  squint,  on  the  other  hand,  the  ex- 
ternal rectus  tendon  is  subjected  to  tenotomy  or  the  internal  tendon 
is  shortened  or  advanced. 

Tenotomy  of  a  rectus  tendon  is  done  through  an  incision  of  the 
conjunctiva  over  it.  It  is  said  that  paralyzing  the  ciliary  muscle  of 
accommodation  for  a  few  days  before  and  after  operation  is  a  benefit. 
This  may  readily  be  done  by  putting  a  drop  or  two  of  atropine  solution 
of  the  strength  of  four  grains  to  the  fluid  ounce  in  the  eye  every  day. 

The  cocaine  solution  used  for  local  anesthesia  should  be  of  the 
strength  of  twenty  or  twenty-five  grains  to  the  fluid  ounce.  Of  this 
one  or  two  drops  should  be  dropped  upon  the  conjunctiva,  over  the 
tendon  to  be  divided,  four  or  five  times  at  intervals  of  four  or  five 
minutes.  The  eyelids  should  be  held  apart  by  means  of  a  stop 
speculum.  The  insertion  of  the  tendon  of  the  internal  rectus  is  about 
five  millimeters  behind  the  edge  of  the  cornea;  that  of  the  external 
rectus  about  two  millimeters  more  than  that  behind  the  external 
corneal  margin. 

With  a  pair  of  small  toothed  forceps  the  operator  seizes  the  con- 
junctiva and  underlying  tendon  of  the  rectus  muscle  opposite  to  the 
one  he  wishes  to  cut.  He  then  rotates  the  eyeball,  with  that  pair  of 
forceps,  until  he  has  brought  from  under  the  canthus  the  conjunctiva 
over  the  tendon  which  is  to  be  divided  to  relieve  the  convergent  or 
divergent  squint.  With  his  other  hand  he  uses  another  pair  of  fixa- 
tion forceps  to  seize  and  lift  in  a  horizontal  fold  the  conjunctiva  overly- 
ing the  tendon.  Releasing  his  first  hold  on  the  eye  he  snips  the  con- 
junctival fold,  the  subconjunctival  tissue  and  the  capsule  of  Tenon 
between  the  second  forceps  and  the  corneal  edge,  thus  making  a  ver- 
tical wound.  The  conjunctiva  retracts  and  discloses  the  insertion  of 
the  desired  tendon. 

Still  maintaining  his  hold  on  the  conjunctiva  with  one  forceps,  he 
inserts  the  other  pair  into  the  wound  and  grasps  the  tendon,  at  a  right 
angle  to  its  length.  With  a  strabismus  hook  the  tendon  is  then  lifted 
a  little  from  the  globe  and  divided  with  blunt  pointed  scissors  close 
to  the  sclera.  The  hook  is  then  swung  carefully  around  both  above  and 
below  the  cut  tendon  to  detect  and  raise  for  division  any  fibers  that 
may  have  escaped  the  first  grasp  of  the  hook.  When  these  also  have 
been  divided,  the  edges  of  the  conjunctival  wound  are  allowed  to  fall 
together  and  the  speculum  is  removed.  The  end  of  the  strabismus 
hook  must  always  be  kept  close  to  the  sclera  when  seeking  to  lift  the 
tendon.  If  a  slightly  greater  degree  of  correction  in  the  deviation  is 
17 


258  SURGERY  OF  DEFORMITIES  OF  THE  FACE 

desired,  the  fascia  about  the  tendon  may  be  more  freely  divided,  or  the 
globe  may  be  grasped  with  forceps  and  be  forcibly  rotated  in  the  direc- 
tion opposite  to  the  squint.  If  less  correction  is  needed  than  has  been 
given,  the  subconjunctival  tissues  and  capsule  of  Tenon  around  the 
divided  tendon  may  be  drawn  together  with  a  catgut  suture.  The 
tendon  should  not  be  stitched.  A  stitch  may  be  placed  in  the  con- 
junctiva if  the  wound  gapes.  This  stitch  will  have  no  special  effect 
on  the  position  of  the  eye  as  the  conjunctiva  is  a  loosely  attached 
covering  of  the  eyeball.  The  effect  of  a  tenotomy  may  sometimes 
be  increased  by  putting  a  thread  through  the  insertion  of  the  cut 
muscle  and  fastening  it  over  a  piece  of  adhesive  plaster  attached  to 
the  skin  beyond  the  other  canthus  of  the  eye.  If  the  effect  is  too 
great  the  divided  tendon  may  be  drawn  partly  together  by  a  stitch. 
The  tenotomy  may  be  done  subjunctively,  if  the  operator  prefer. 
The  incision  is  then  made  horizontally.  If  the  change  of  position  of 
the  eye  required  is  thought  to  be  obtainable  by  mere  division  of  the 
tendon,  care  should  be  taken  to  avoid  as  much  as  possible  tearing  up 
the  fascia  around  the  muscle  and  its  tendon.  It  is  then  best  to  divide 
the  conjunctiva,  by  the  open  or  subcutaneous  method,  and  do  a  neat 
tenotomy  without  much  cutting  of  fibers  of  connective  tissue  or  of 
the  capsule  of  Tenon. 

When  it  is  found  that  tenotomy  of  one  eye  has  not  been  sufficient 
to  correct  the  strabismus,  the  other  eye  may  need  the  internal  rectus 
divided  in  the  same  way.  If  the  double  tenotomy  is  insufficient,  one, 
or  perhaps  both  of  the  eyes  may  require  an  advancement  or  shortening 
of  the  external  rectus  tendon.  In  operations  on  the  external  rectus 
tendon,  the  surgeon  should  recollect  that  its  insertion  on  the  sclera 
is  a  little  further  from  the  border  of  the  cornea  than  is  that  of  the  in- 
ternal rectus. 

Operations  for  correcting  external  squint  are  conducted  in  the  same 
way  as  those  for  overcoming  internal  squint,  except  that  they  are 
performed  on  opposite  muscles. 

The  operation  of  advancement  or,  of  shortening  of  a  tendon  is  per- 
formed when  the  surgeon  desires  to  increase  the  power  of  a  rectus 
muscle  to  pull  the  eye  in  the  direction  in  which  it  acts.  It  is  the 
weaker  muscle  which  is  thus  operated  upon,  as  it  is  the  muscle  which 
is  too  strong,  that  is  subjected  to  the  simple  tenotomy  just  described 
so  that  it  will  become  longer  and  weaker.  Advancement  is  performed 
by  opening  the  conjunctiva  with  a  vertical  cut,  between  the  border  of 
the  cornea  and  the  insertion  of  the  muscle  to  be  operated  upon. 
Tenon's  capsule  is  next  opened  at  the  lower  border  of  the  tendon  and 
a  hook  passed  under  the  muscle.     The  muscular  belly  and  tendon  are 


DEFORMITIES  OF  THE  EYELIDS  AND   EYEBALL  259 

then  dissected  free  from  their  attachments  except  at  the  in- 
sertion into  the  sclera.  Three  strong,  though  fine,  sutures  are 
then  passed  through  the  conjunctiva  over  the  muscle,  and  through 
the  capsule  of  Tenon  and  the  muscle  itself.  One  suture  from  behind 
forward  passes  through  the  center  of  the  muscle  and  the  other  two 
through  it  near  its  upper  and  lower  edge  respectively.  The  tendon 
of  the  muscle  is  then  divided  near  its  scleral  insertion.  A  small 
section  of  the  tendon  is  excised,  if  a  marked  shortening  of  the  muscle 
is  desired.  Otherwise  no  portion  is  removed,  because  the  overlapping 
to  be  obtained  when  the  sutures  are  tied  will  be  sufficient.  The 
needle  carrying  the  central  stitch  is  then  made  to  pass  horizontally 
through  the  superficial  layers  of  the  sclerotic  coat,  at  the  point  where 
the  tendon  was  originally  attached,  and  to  emerge  from  the  sclera 
near  the  cornea.  The  two  marginal  sutures  are  carried  toward  the 
cornea,  one  going  oblic^uely  upward,  the  other  obliquely  downward. 
Then  keeping  beneath  the  conjunctiva  they  pass  through  the  super- 
ficial layers  of  the  sclera  so  as  to  come  out  of  its  tough  tissue  a  little 
above  and  a  little  below  the  center  of  the  cornea.  Tying  these  three 
sutures  rotates  the  globe  of  the  eye  toward  the  origin  of  the  muscle 
and  therefore  overcomes  the  deviation  which  existed  prior  to  the 
operation.  The  conjunctival  wound  is  then  closed  with  stitches. 
The  amount  of  advancement  given  the  insertion  of  the  tendon  by  the 
overlapping  of  its  cut  ends  or  the  degree  of  shortening  acc^uired  by 
the  muscle,  because  of  the  excision  of  a  part  of  its  tendon,  will  determine 
the  result  of  the  procedure. 

The  sutures  should  not  be  removed  for  a  week  or  more;  and  the 
surgeon  should  over-correct  the  deformity  by  his  stitches.  It  is 
unusual  to  be  able  to  maintain  the  exact  position  of  the  ball,  which  is 
seen  when  the  stitches  are  tied.  If  after  operation  the  position  of  the 
e^^e  seems  to  have  been  corrected  too  much,  the  sutures  may  be 
removed  early  or  a  looser  stitch  inserted,  and  there  will  be  some  degree 
of  return  of  the  eye  to  its  former  position. 

Care  should  be  taken  in  tenotomy  of  the  tendon  of  the  internal 
rectus  muscle  not  to  tear  up  tissues  sufficiently  to  cause  sinking  of 
the  caruncle  at  the  internal  canthus.  It  may  be  due  to  too  much 
retraction  of  the  divided  muscle.  If  this  occur,  the  contracted  tis- 
sues may  be  dissected  up  and  stitched  into  place,  or  the  muscle  ad- 
vanced. Sometimes  a  mass  of  red  granulation  tissue  is  developed 
in  the  conjunctival  wound.  This  may  be  snipped  off  with  sharp 
scissors  and  cicatrization  follows. 

Some  operators  close  the  eyes  and  l_)andage  them  for  a  few  days; 
others  allow  them  to  be  open  during  the  after  treatment. 


INDEX. 


A 

Abnormal  growth  of  hair SO 

Absence  of  eyeballs 215 

eyelids 216 

eyes 245,  248 

Acne 70 

rosacea 70 

Adhesion  of  eyelids 223 

Aged,  head  of 17 

Ala  of  nose,  restoration  of 122,  207,  209 

Alveolus,  cleft  of 109,  120 

operation  for 120,  122,  124,  125 

Anaplasty 5 

Anatomy  of  the  face,  survey  of 9 

Angeioma 76 

treatment  of,  with  boiling  water 78 

Angle,  facial,  of  Apollo 20 

Camper 19 

Caucasian  skull 18 

negro  skull 18 

Ankyloblepharon 223 

Ankylosis  of  lower  jaw 62,  63,  96 

cicatricial 96 

Anophthalmos 215 

Antihelix,  angle  of 162,  164,  165 

insufficient 162 

Apparatus,  etherizing,  Rupert's 119 

Artificial  eyes 248 

nose 214 

vitreous  body 247 

Atheroma 70 

Atresia  oris 85 

Atrophy  of  bones  of  face 61 

Attention,  muscle  of 23 

Auricle,  absence  of 153 

anomalies  of 153 

deformities  of 153,  160 

flaring 162,  166 

frost-bite  of 159 

gigantic 162,  166,  167,  168 

inj  uries  of 159 

Autoplasty 5 

261 


262  INDEX. 

B 

Ball,  gold,  as  artificial  vitreous 245 

glass,  as  artificial  vitreous 245 

Bite,  errors  in 147,  149,  152 

Blepharoplasty 226,  231,  234,  237 

Bones  of  face 9 

atrophy  of 61 

deficiency  of 61 

Brachial  flap  in  rhinoplasty 196 

Brophy's  operation  for  cleft  palate 117,  127 

Burns , 48,  85 

deformities  of  mouth  from 85 

C 

Camper,  angle  of 19 

Canthoplasty 222 

Canthotomy 223 

Cartilages  of  nose 175 

Cartilaginous  defects  of  ear 160 

Cerebral  meningocele 60 

Characteristics  of  surgery  of  the  face 29 

Cheek,  malignant  disease  of 94 

reconstruction  of 47,  94,  145,  147 

Cheiloplastic  operations 102,  107,  109,  139,  141 

Chloasma 71 

Cleft  of  cranium 99 

eyelids 99,  216 

face 99 

lip  and  palate 101 

lower  jaw 99 

mouth 88 

nose 170 

palate 100 

upper  lip 99 

Cleft-palate 100,  112 

anesthesia  in 119 

cervical  flap  in 140 

clamp  for 114 

complete 112 

incomplete 112 

nipple  for 138 

obturators  in 130,  135,  136,  138 

operation  for,  time  of 116 

Brophy's  flap 127 

osteoplastic 116 

Davies-CoUey's 131 

Fergusson's 129 

Lane's 125,  133 

operations   for 117,  122 


INDEX.  203 

Cleft-palate,  operations  for  atypical 134 

flap 122 

periosteal  separators  for 128 

repetition  of 138 

treatment  of 1 1 4,  122 

Columella  of  nose 209 

Comedo 69 

Conjunctiva,  tumors  of 241 

Contraction  of  the  mouth 87 

Cornea,  deformities  of 242 

grafts  of 243 

leucoma  of 243 

staphyloma  of 242 

tattooing  of 243 

Corneal  staphyloma 242 

Crosseyes 254 

Cyst,  sebaceous 70 

D 

Deficiency  of  bones  of  face 61 

nose 213 

Deformities,  congenital 85,  88,  99,  112,  154,  169,  215 

from  paralysis 95 

orbital  growths 251 

tumors 190 

of  cornea 242 

ear 153 

eyeballs 215,  241 

eyelids 215 

face,  due  to  removal  of  bone 95 

lips 85,  99,  141 

mouth 85 

nose. 169 

Dental  disfigurements 97 

Dentition,  changes  due  to 18 

Dermatolysis 79 

Dermoid  cyst  of  nose 82 

Development  of  plastic  surgery 1 

Disfigurements,  dental 97 

of  eyeball 241 

Dislocations  of  nose 177,  184 

Displacement  in  plastic  surgery 35 

Distortions,  cicatricial 45,  52,  53 

Duct  of  parotid  gland 33,  55,  56,  57 

E. 

Ear,  absence  of 154,  157 

Roberts's  operation  for 158 

Szymanowski's  operation  for 157 

artificial 156 


264  INDEX. 

Ear,  cartilaginous  defects  of 160 

deformities  of 153,  160 

flaring 162,  I69 

frostbite  of 159 

gigantic 162,  166,  167,  168 

injuries  of 159 

lop 161 

outstanding 162,  165,  166 

prominent 162,  165,  166 

supernumerary 155 

transplantat  on  of 155 

tumors  of 163,  167 

Ectropion  of  eyelids 226 

lips 90 

Ehrlich's  remedy  for  syphilis 45 

Electrolysis  in  treatment  of  abnormal  growths  of  hair 81 

moles 75 

naevus 76 

Elephantiasis 67,  79 

Emphysema,  local 41 

Encephalocele 60 

Enophthalmos 245 

Entropion  of  eyelids 236 

Enucleation  of  eyeball 245 

Epicanthus 183,  218 

Epithelioma 74 

Etherizing  apparatus,  Rupert's 119 

Evisceration  of  eyeball 247 

Exophthalmos 245 

Expression,  muscles  of 20 

anatomical  basis  of ". 27 

Extirpation  of  orbital  contents 248 

Eyes,  angeioma  of : 217 

artificial 245,  248 

congenital  deformities  of 215 

Eyeball,  absence  of 215 

deformities  of 215 

deviations  of 241,  254 

disfigurements  of 241 

enucleation  of 245 

evisceration  of 246,  247 

Eyebrow,  restoration  of 238 

Eyelashes,  illy  grown 237 

ingrowing 237 

Eyelids,  absence  of 216 

adhesion  of 223 

cleft  of 216 

cyst  of 216,  217 

ectropion  of 226,  238 

entropion  of 236,  240 


INDEX.  265 

Eyelids,  eversion  of 226 

restoration  of 231 

reconstruction  of 231 

tumors  of 217 

Eyesockets,  anatomy  of 10 

extirpation  of  contents  of 248 

F 

Face,  abscess  of 46 

anatoni}^  of 9 

arteries  of 14 

atrophy  of  bones  of 62 

bones  of 9 

clefts  of 99 

deficiency  of  bones  of 62 

deformities  due  to  loss  of  bone 95 

paralysis 96 

fractures  of,  depressed 42 

fissure  of , 99 

hemiatrophy  of 64,  146 

hyperostosis  of 67 

hypertroph}'  of 66 

incisions  in 29 

maUgnant  disease  of 47 

muscles  of 20,  22 

nerves  of 14 

of  aged 18 

infant 16 

plastic  surgery,  principles  of 34 

septic  inflammations  in  the 30 

surgery  of,  characteristics  of 29 

dressings  in 31 

sutures  in 31 

tumors  of 46 

ulcers  of 46 

veins  of 30 

wounds  of 39 

Facial  changes  due  to  dentition ' .  .  18 

Fissures 55 

of  hp 99 

mouth 88 

palate 100,  112 

palate,  treatment  of 114,116 

Fistules 55 

congenital 55 

from  accessory  sinuses  of  nose 56,  58 

diseased  teeth 56 

of  antrum  of  jaw 59 

hp 88 

lachrvnial  sac 60 


266  INDEX. 

Fistules,  parotid  duct 55,  57 

salivary 55,  56 

treatment  of 57 

Flaps 35 

brachial  in  rhinoplasty 196 

pedunculated 37 

free 38 

without  a  pedicle 38 

Fractures  of  nose 177,  184,  187 

old.. 187,212 

treatment  of 188 

Freckles 71 

G 

Gangrene 31,39 

Gland,  parotid 15 

duct  of 33,  55,  56,  57 

Grafts  in  plastic  surgery 36,  243 

Grief,  muscle  of 24 

Gums,  affections  of 97 

Gunpowder  discolorations 144 

H 

Hair,  abnormal  growth  of 80 

electrolysis  in 81 

absence  of 81 

loss  of 81 

HareUp .      99 

bilateral 108 

deviated  nasal  septum  in 110 

flattened  nostril  in 104,  105,  106 

incisions  in  operation  for 102,  104,  107,  108,  111 

projection  of  intermaxillary  bone  in 100,  110 

time  of  operation  for 101 

treatment  of 101 

unilateral 100 

V  excision  of  lower  lip  in 109 

with  cleft  palate 109 

Head,  flexion  of 92 

of  aged 17 

infancy 16 

Hemiatrophy  of  face 64,  146 

Horns 72,  74 

Hydrencephalocele 60 

Hypertrophy  of  face 66,  67 

tongue 98 

Hyperostosis  of  face 67 

jaws 67 

I 

Implantation  therapy 8 


IXDEX.  2G7 

Incisions 29 

leaving  inconspicuous  scars 29 

Infanc}',  head  of 16 

Inflammation,  septic 30 

Intermaxillary  bone,  projection  of 100,  110,  121 

Interpolation  in  plastic  surgery 35 

J 

Jaw.  lower,  anatomy  of 11 

atrophy  of 12,  63 

anchylosis  of 63,  96 

artificial 146 

cleft  of 99 

fissure  of 99 

hyperostosis  of 67 

upper,  anatomy  of 11 

depressed  fracture  of 11,  lol 

hyperostosis  of 67 

K 

Keloid  growths 49 

excision  of 52 

Kroenlein's  operation  for  orbital  growths 253 

L 

Lane's  operation  for  cleft  palate 125 

Lentigo 71 

Leontiasis 68 

Leucoderma 72 

Leucoma  of  cornea 243 

Line,  naso-labial 25,  26 

Lip,  double 90,  91 

eversion  of 90,  92,  93 

lower,  double 108,  111 

excision  of  V  from 109,  139 

protruding 109 

tumors  of 86,  87,  95,  96 

upper,  angeioma  of 89 

fissure  of 99,  141 

combined  with  cleft  palate 101 

operation  for 102 

operations  for,  secondary 107 

time  for 101 

hypertrophy  of 89,  90 

Lips,  deformities  of 85,  95 

ectropion  of 90,  92,  93 

eversion  of 90,  92,  93 

hypertrophy  of 89,  91 

plastic  operations  on 141 

Liver  spots 71 

Lupus S3 


268  INDEX. 

Lymphangioma 79 

Lymph  nodes,  tuberculous 46 

M 

Macrostoma 83 

Malar  bone,  anatomy  of .  . 10 

Malar  region,  hollows  in ■. 152 

Malignant  disease  of  cheek  and  mouth 87,  93 

Malocclusion  of  teeth 152 

Mandible,  anatomy  of 11 

anchylosis  of 63 

artificial 146 

atrophy  of 12,  63 

cleft  of 99 

fissure  of 99 

Maxilla,  depressed  fracture  of 151 

Meatus,  external  auditory,  absence  of 154,  159 

Meloplasty 47,  94,  145,  147 

Menace,  muscle  of 27 

Meningocele,  cerebral 61 

Microphthalmos 216 

Microstoma .      87 

Mihum 69 

Moles 72,  74 

Molluscum  verrucosum 70 

Mother's  mark 76 

Mouth  and  lips,  deformities  of 85,  95 

accidental  increase  in  size  of •  .      88 

cleft  of 88 

contraction  of 87 

occlusion  of ,- 87 

fissure  of 88 

Mules'  operation  on  eyeball 246 

Muscles  of  expression ■ 20 

palate,  division  of 129 

Mutilation  of  noses 2 

N 

Naevus 76 

Nasal,  aperture 10 

pins 172 

septum  of : 170,  212 

septum,  deflected 110 

splints 1 72 

structures,  fractures  of 184 

dislocations  of 184 

Nasolabial  fine 25,  26 

Nerve,  facial,  injury  of 14,  33 

seventh 14,  33 

spinal  accessory,  anas  omosis  of 147 

trifacial 14 


INDEX.  269 

Nerves,  of  face 14 

Nipple  for  cleft  palate  cases 138 

Nodes,  lymph,  tuberculous 46 

Nostril,  flattened,  in  harelip 105 

occlusion  of 172 

Nose,  absence  of,  congenital 169 

ala  of,  flattened 122,  169,  207 

angular 171,  175 

bent 170,  176 

cartilages  of 175 

cleft  of : 170 

columella  of 209 

crooked 170,  178 

deficiency  of 213 

deformity  of 169 

dermoid  cyst  of 82 

deviated  septum  of 170,  172 

dislocation  of 172,  177,  178,  184,  186,  188,  190 

fractures  of 172,  177,  178,  184,  186,  187,  188,  190 

old 187,  212,  213 

gigantism  of 182,  183 

hemorrhage  from 179 

lobule  of 211 

reconstruction  of 207 

mutilation  of,  oriental 2 

necrosis  of 173 

occlusion  of 49 

paraffin  treatment  of  nasal  deformity 180 

plugging  in  hemorrhage 179 

punitive  loss  of 2,  195 

reduction  of  fracture-dislocation  of 189,  190 

restoration  of 207 

saddle 171,  180,  209 

septum  of,  restoration  of 208 

splints  for 172 

sunken 173,  180 

syphiHtic 160,  180,  182,  195,  205 

tuberous 171 

tumors  of 190 

twisted 170,  176 

O 

Obturator  for  cleft  palate 135,  136,  138 

Occlusion  of  the  mouth 87 

Operations  on  the  nose 190,  195 

to  reach  interior  of  the  nose 190 

Orbit,  tumors  of 251 ,  252,  253 

Orbital  contents,  extirpation  of 248 

growths 251,  252,  253 

Osteoplastic  resections 192 


270  INDEX. 


Paraffin 8 

injection  of 63,  180 

into  eyeball 247 

in  saddle  nose 180 

syringe  for 174 

Parotid  gland,  anatomy  of 15 

duct  of 33 

fistules 55,  56,  57 

Palate,  cleft  of - 100,  112 

anesthesia  in 119 

clamp  for 114 

complete 112 

incomplete .  .  .  . 112 

nipple  for 138 

obturator  for 130,  135,  136,  138 

operation  for 116,  122 

atypical 134 

flap 122 

Brophy's 127 

Brophy's  osteoplastic 116 

Davies-CoUey's 131 

Fergusson's 129 

Lane's .  .  .125,  133 

repetition  of 138 

periosteal  separators  for 128 

tensor  and  elevator  muscles  in.  . 129 

treatment  of 114,  122 

cervical  flap  in 140 

time  of 114 

perforations  of,  syphilitic 140 

Palpebral  opening,  changing  size  of 222 

Papilloma 73 

Periosteal  separators 128 

Plastic  surgery,  contributions  to.  Carrel's 8 

Gluck's 7 

Krause's 7 

Lexer's 8 

Mutter's 5 

Reverdin's 6 

Szymanowski's 6 

Thiersch's 7 

Wolfe's : 7 

development  of 1 

displacement  in 36 

in  non-medical  literature 2 

interpolation  in 35 

methods  of 35 

objects  of 34 


INDEX.  271 

Plastic  surgery,  principles  of 34 

retrenchment  in 36 

revival  of 1 

transplantation  in 36,  38 

Portwine  mark 76 

Principles  of  plastic  surgery  of  face 34 

Prosthetic  appliances • 48,  213 

for  the  nose 213 

Protrusion  of  teeth 150 

Ptosis 219 

treatment  of 220 

R 

Retrenchment  in  plastic  surgery 36 

Rhinoplasty 195 

Bardenheuer's  method 204 

Keegan's  method 197 

Nekton's  method 199.  200.  201,  203 

Roberts'  method 206 

Schimmelbusch's  method 202 

Smith's  method 198 

brachial  flaps  in 196 

frontal 197.  198 

for  syphihtic  noses 160,  180,  182,  195,  205 

Rhinoscleroma 80 

S 

Salivary  fistules 55,  56,  57 

Scars 45 

depressed 53.  54 

distortions  from 45 

smooth 72 

stretching  of 52 

white,  tattooing  in 54 

Scleroderma 80 

Scorn,  muscle  of 25 

Sebaceous  cyst 70 

Sinuses 57.  60.  154 

Skin,  stretching  of 52 

syphilis  of 84 

tumors  of 82 

Skingraf ting 6.  36 

Krause's  method 7 

Reverdin's  method 6 

Thiersch's  method ' 

Wolfe's  method ' 

Spinal  accessory  nerve,  anastomosis  of 14  < 

Splint,  gypsum,  in  facial  surgery 146 

Splints,  intrana.sal 172 

Squint 254 

tenotomv  for 256 


272  INDEX. 

Staphyloma  of  cornea 242 

Staphylorrhaphy,  see  operations  for  cleft  of  soft  palate. 

Strabismus 254 

operation  for 256 

refractive  errors  in 254 

tenotomy  for 256 

treatment  of 255 

Surgery  of  face,  plastic,  characteristics  of 29 

development  of 1 

general  methods  of 35 

in  literature 2 

objects  of 34 

principles  of 34 

revival  of 1 

Szymanowski's  manual  of 6 

Survey  of  anatomy  of  face .  .• 9 

Sutures 31,41 

intracutaneous 32 

Symblepharon 224 

Syphilis  of  skin 84 

Syphilitic  nose • 84,  1 73 

perforations  of  hard  palate 140 

ulcers 45 

Syringe  for  paraffin  injection 174 

Szymanowski's  manual 6 

T 

Tattooing 44,  54,  71 

Teeth,  importance  of 16 

disfigurements  from 97 

malocclusion  of ' 147,  149,  152 

protrusion  of 1 50 

Tongue,  hypertrophy  of 98,  149 

Toxines  of  erysipelas  in  keloid  growths 52 

Transplantation  in  plastic  surgery 36 

of  corneal  grafts 243 

Tuberculosis  of  face 83 

Tuberculous  lymph  nodes 46 

Tumors,  excision  of 46 

of  conjunctiva 241 

skin 82 

orbit 251 

Treatment  of  gunshot  wounds 42,  44 

keloid  growths 50 

wounds  of  face 39 

facial  nerve 14,  33 

parotid  duct    15,  33 

U 

Ulcers  of  face 46 

Uranoplasty,  see  operations  for  cleft  of  hard  palate. 


INDEX.  273 

V 

V-shape  incision  in  harelip  operations 109,  139 

Vitiligo • 72 

Vitreous  body,  artificial,  insertion  of 246 

W 

Warts 72,  73 

x-ray  in  treatment  of 74 

Wounds,  gunshot 42 

treatment  of 42 

of  duct  of  parotid  gland 15,  33,  55,  56,  57 

face 39 

treatment  of 40 

facial  nerve 14,  33 

X 

X-ray  in  cutaneous  tuberculosis 84 

epithelioma 74 

keloid  growths 51 

warts 74 

Z 

Zygomatic  region,  hollows  in 152 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  523  .R542  1912  C.1 

Surgery  of  deformities  of  tlie  face 


2002093456 


